James Rachels's Defense of Active Euthanasia: A Critical & Normative Study

James Rachelss Defense of Active Euthanasia:
A Critical & Normative Study
Mr. Mohammad Manzoor Malik
A THESIS SUBMITTED IN PARTIAL FULFILLMENT OF THE

REQUIREMENT FOR THE DEGREE OF DOCTOR OF
PHILOSOPHY IN PHILOSOPHY
Graduate School of Philosophy and Religion

Assumption University, Thailand
June, 2008
Dissertation Title: James Rachelss Defense of Active Euthanasia: A Critical and
Normative Study
Researcher: Mr. Mohammad Manzoor Malik
Adm. No. : 462-9481
Degree: Doctor of Philosophy
Majoring in: Philosophy
Advisor: Assistant Professor Dr. Warayuth Sriwarakuel
Academic Year: 2008
ABSTRACT
The researcher believes that James Rachelss defense of active euthanasia
deserves a critical and normative analysis because of its dehumanizing consequences.
The researcher demonstrates that Rachelss position is conceptually, theoretically,
practically, and normatively unjustifiable. The researcher supports his position by three
steps.
Firstly, the researcher criticizes Rachelss conceptual framework which
consists of three distinctions: biological and biographical life; killing and letting die;
and ordinary and extraordinary medical treatment. The research shows that these
distinctions do not provide a valid foundation or criteria for the permissibility of active
euthanasia because of their conceptual, theoretical, and practical inadequacies.
Rachelss first distinction is inadequate due to: (1) reductive fallacy (2) slippery slope
and (3) irrelevance to main arguments. His second distinction is: (1) irrelevant, (2)
extraneous and (3) degressive. His repudiation of the distinction of ordinary and
extraordinary medical treatment is not valid.
Secondly, the researcher argues against Rachelss arguments against CDE.
Rachels proposes four arguments which make the distinction between active and
ii
passive euthanasia morally absurd. Therefore, Rachels argues that wherever passive
euthanasia is allowed, active should be permitted too. The researcher shows that
Rachelss arguments are theoretically flawed to support his position because most of
his premises are either irrelevant or weak. Rachelss first claim is that often active
euthanasia seems more humane than passive and therefore active euthanasia should not
be only permitted but preferred too. The research shows two main responses to
Rachelss claim which render his argument invalid. The first response is that Rachels
argues against CDE on the basis not included in the AMAs statement. The research
forwards the reasons which render Rachelss argument unimportant, irrelevant, and
inadequate. Rachelss second claim is that the conventional view makes life-and-death
decisions on irrelevant grounds therefore the conventional view, CDE, is not true. The
research shows that the relevant grounds in CDE are the killing and termination of
extraordinary medical care. Rachelss third claim is that there is no moral difference
between doings and refraining, therefore wherever refraining is allowed doing should
be permitted too; in other words, wherever passive euthanasia is allowed active should
be allowed too. The research shows that Rachelss argument is invalid due to four
reasons: (1) irrelevance to AMAs statement; (2) differences between the cases because
of intentionality, causality, and agency; (3) straw man fallacy, and (4) weak analogy.
Thirdly, the researcher analyzes and argues against Rachelss direct arguments
for active euthanasia which are from best interests and golden rule and autonomy. The
researcher shows that the arguments are based on subjective moral claims and such
claims are based on indefensible claims from liberty, rights and autonomy. The
research demonstrates three reasons which render the best interest and golden rule
iii
argument invalid. They are: (1) the argument is based on subjective moral judgment,
failing the universalization test; (2) it may not be in my own best interests or in the best
interests of others for me to die; and (3) the argument is based on indefensible
autonomy. Rachelss third argument is from autonomy. The research demonstrates that
argument from autonomy fails to claim the sufficient support to substantiate a
pro-position for the approval of active euthanasia. The related reasons are: (1)
invalidity of civil rights claim; (2) weak analogy (3) unwarranted influence of
patients autonomy, and (4) unattainable autonomy of the patients. Furthermore,
Rachels proposes a modest proposal for the legalization of active euthanasia. The
research demonstrates that Rachelss proposal on legalizing active euthanasia is
problematic and impractical.
Finally, the researcher shows that Rachelss categorization of active and
passive euthanasia into killing and letting die is a false dichotomy. The researcher
argues throughout the research that the third and the only choice is to stop prolongation
of death by advanced medical technology and permitting termination of extraordinary
medical care from dying person by following legitimate procedures.

CONTENTS
Page
Abstract i
Acknowledgements iv
Contents v
Chapters
Chapter One: Introduction 1
1.1. Background, Significance, & Scope of the Study 1
1.2. Thesis Statement 19
1.3. Objectives 19
1.4. Limitation and Methodology of the Research 19
Chapter Two: Exposition of Rachelss Thought on Euthanasia 21
2.1. Introduction 21
2.2. Rachelss Euthanasian Conceptual Framework 23
2.2.1. Biological Life and Biographical Life 23
2.2.2. Killing and Letting Die 24
2.2.3. Ordinary and Extraordinary Means of Treatment 27
2.3. Rachelss Arguments against Traditional Doctrine
on Euthanasia (TDE) 30
2.3.1. Often Active Euthanasia Seems More Humane Than Passive 32
2.3.2. The Conventional View Makes Life-And-Death Decisions
on Irrelevant Grounds 33
2.3.3. There is no Moral Difference between Doing and Refraining 34

vi
2.3.4. Arguments in Favor of the Conventional View do not Work 35
2.4. Rachelss Arguments for Active Euthanasia 36
2.4.1. The Argument from Mercy 37
2.4.2. The Best Interests and Golden Rule Argument 37
2.4.3. The Argument from Autonomy 40
2.5. Proposal for Legalization of Active Euthanasia 42
Chapter Three: Critique of Rachelss Thought on Euthanasia 45
3.1. Introduction 45
3.2. Criticism of Rachelss Conceptual Framework 46
3.2.1. Criticism of Biological and Biographical Life 46
3.2.2. Criticism of Killing and Letting Die 53
3.2.2.1. Killing and Letting Die: An Irrelevant Distinction 54
3.2.2.2. Killing and Letting Die Distinction and Health Care Professions 57
3.2.3. Criticism of Ordinary and Extraordinary Means of Treatment 61
3.3. Criticism of Rachelss Arguments against Traditional
Doctrine on Euthanasia (TDE) 66
3.3.1. Criticism of that often Active Euthanasia Seems More
Humane than Passive 67
3.3.2. Criticism of the Conventional View Makes Life-And-Death
Decisions on Irrelevant Grounds 75
3.3.3. Criticism of that there is no Moral Difference between
Doings and Refraining 77

vii
3.3.4. Criticism of that the Arguments in Favor of the Conventional
View do not Work 86
3.4. Criticism of Rachelss Arguments for Active Euthanasia 88
3.4.1. Criticism of the Argument from Mercy 90
3.4.2. Criticism of the Best Interests and Golden Rule Argument 90
3.4.3. Criticism of Rachelss Argument from Autonomy 96
3.4.3.1. Self-determination and Euthanasia 97
3.4.3.2. Analogy of Euthanasia with Suicide 100
3.4.3.3. Right, Liberty and Euthanasia 101
3.4.3.4. Autonomy of Patients 103
3.5. Criticism of Rachelss Proposal of Legalizing Active Euthanasia 105
3.6. Modern Advanced Medical Technology and Euthanasia 107
3.6.1. Moral Hazards of Modern Advanced Medical Technology 108
3.6.2. Passive Euthanasia is not Euthanasia / Letting Die 113
3.6.3. Active Euthanasia is Mishandling of those whose
Death is Prolonged 116
Chapter Four: Conclusion 122
Further Research and Recommendations 141
References 142
Autobiography
Acknowledgments
The researcher would like to extend his special gratitude to his dissertation advisor
Assistant Professor Dr. Warayuth Sriwarakuel for advising, inspiration,
encouragement, concern and moral support.
Likewise, the researcher extends his gratitude to all the instructors and class mates for
their meaningful comments on and suggestions to this research during seminar class
presentations.
The special words of thanks are offered to Dr. Imtiyaz Yousuf, Dr. Veerachart
Nimanong, Dr. Joseph I. Fernado and Dr. John Thomas Giordano for their
encouragement and motivating affection.
Finally, thanks to family and friends.

CHAPTER ONE
Introduction
1.1. Background, Significance, & Scope of the Study
This research is a critical and normative study of James Rachelss defense of
active euthanasia. And by its academic and disciplinary nature, it falls within the
philosophical discussions in medical ethics and legal theory. The research is critical and
normative: Rachelss positions and arguments are conceptually, theoretically, and
practically criticized; and his normative conclusions are challenged. In brief, the
research is aimed at establishing the claim that James Rachelss defense of active
euthanasia is conceptually, theoretically, practically, and normatively unjustifiable. To
put Rachelss case briefly, he provides his own conceptual framework for the resolution
of the issues related to euthanasia (Rachels, 1981 / 1994b, 1986b); he allegedly makes
the distinction between active and passive euthanasia morally absurd (1975 / 1994a),
and he finally argues in defense of active euthanasia (Rachels, 1981/ 1994b). In
addition, Rachels provides a modest proposal for the legalization of active euthanasia
(Rachels, 2003). Furthermore, Rachels argues that the opponents can not defend
themselves rationally rather their position, according to him, is based on a muddle of
indefensible claims, backed by tradition but not by reason (1981 / 1994b, p. 153). On
the whole, Rachelss position on euthanasia is widely known as libertarian approach in
contrast to traditional doctrine or conventional approach. Libertarian approach allows
active euthanasia mercy killing, whereas the traditional approach approves passive
euthanasia in the sense of terminating extraordinary medical treatment and does not
Introduction 2
permit active euthanasia.
The driving motivation for the topic stems from researchers conviction that
contemporary, intellectual discourse in support of euthanasia has potential
consequences of leading to dehumanization, which ought to be rejected. The researcher
thinks that permissibility of active euthanasia will lead to reducing a human being to a
product, which at the point of loosing its usefulness is disposed. As a result, human
beings will end up being treated as disposable products rather than dignified persons.
Euthanasia, by definition, is supposed to be for terminally ill persons; therefore children,
adults, and elderly people are subjects to it, however, elderly people are the most
vulnerable. The harshness of euthanasia supporters could be understood from what
Colorado governor Richard D. Lamm said in an address, which was reported in The
New York Times, March 29, 1984, to the Colorado Health Lawyers Association :
"Elderly people who are terminally ill have a duty to die and get out of the way (Kearl ,
1989, p.125). Similarly, Richard Fenigsen, who conducted research on Dutch elderly
people, argues that a society which promotes euthanasia sends a message to the
vulnerable that their lives are not valued. Instead, such a society tells them, we
wouldn't mind getting rid of you (Fenigsen, 1989, Social Implications, para. 1). It
should be noted that active euthanasia is legal in Holland.
To return to the subject of euthanasia, it is of importance to mention that the
issue of euthanasia is both new and old. It is new in the sense that most of the debate on
the issue treats the matter as a consequence of the modern advanced medical
technology. As a matter of fact, the rise of advanced medical technology, especially the
artificially life-sustaining technology, has brought various moral issues to center stage
Introduction 3
such as people can be kept alive against their wishes or in states of pain and in other
forms of suffering. Moreover, it is also possible to keep people alive who are in a coma
or a persistent vegetative state. In cases like these, the use of medical technologies
raises questions about the moral appropriateness of sustaining life versus taking life or
allowing someone to die. On the other hand, the issue of euthanasia is old in the sense
that it involves issues of life and death on which thinkers and philosophers, from the
ancient time, have held positions. The involvement of concepts such as killing and
letting die, omission and commission, rights and duties, intrinsic value and inviolability
of life, intention and foresight, and autonomy and paternalism are such issues which
directly or indirectly touch the issue of euthanasia from many perspectives and link the
issue with the philosophical tradition.
In the following parts of the chapter and in the rest of the research, the
researcher provides the exposition of the issue of euthanasia; its historical origins and
relevance with historical, philosophical debate on suicide; and its full development in
our contemporary time. The crucial part of the research comprises of critical exposition
of James Rachelss thought on the issue of euthanasia and its critical and normative
study, which will eventually lead to evaluation of the issue in the third chapter and the
justification of the thesis statement in the final chapter.
First and foremost, it is very important to have a clear definition of euthanasia.
As a matter of fact, defining euthanasia and the relevant synonymous terms deserve a
thorough tactful analysis because much of the confusion which besets the
contemporary euthanasia debate can be traced to an unfortunate imprecision in
definition. Lack of clarity has hitherto helped to ensure that much of the debate has
Introduction 4
been frustrating and sterile (Otlowski, 1997, pp. 16-17). Therefore, defining
euthanasia and the related terms is necessary in the outset of this research to ensure that
conceptual framework of the subject remains clear, justice with reducing conclusions to
proper definitions is realized, and the debate remains equivocation-free.
Euthanasia etymologically comes from two Greek words, eu, well, and thanatos,
death, it means good or easy death (Baird & Rosenbaum, 1989, p. 9). Gradually the
meaning of one word changed from the connotation of easy death to the actual medical
deed necessary to make death easy. Finally it reached the connotation of mercy killing.
Therefore, the common synonym for euthanasia in both lay and professional
vocabularies has been mercy killing (Koop, 1989a, p. 69). Merriam-Webster's
dictionary defines euthanasia as "an easy and painless death, or, an act or method of
causing death painlessly so as to end suffering: advocated by some as a way to deal with
victims of incurable disease" (2008). Similarly, the Euthanasia Society of America,
founded in 1938, defines euthanasia as the "termination of human life by painless
means for the purpose of ending severe physical suffering" (Hardon, 2004, Euthanasia,
para.14). The American Medical Associations Council on Ethical and Judicial Affairs
(1992) defines the term as follows: Euthanasia is commonly defined as the act of
bringing about the death of a hopelessly ill and suffering person in a relatively quick
and painless way for reasons of mercy (p. 2230).
The above definitions show that euthanasia is mercy killing in the sense of
painlessly putting to death a terminally ill patient; however, there are other definitions
which suggest that euthanasia also means refusing unwanted care or withdrawal of
ongoing care (Adams, 1992, p. 2021). Therefore, there are two different uses of the
Introduction 5
term euthanasia. The first is sometimes called the narrow construal of euthanasia. In
this view euthanasia is equivalent to mercy killing. Thus, if a physician injects a patient
with a drug with the intent to kill the patient, that would be an act of euthanasia; but if
the physician withholds some extraordinary and excessively burdensome treatment
from a patient and allows the patient to die in a natural way , that does not count as an
example of euthanasia. The second view, sometimes called the broad construal of
euthanasia, includes within the definition of euthanasia both mercy killing and
cessation of extraordinary medical treatment i.e. active euthanasia and passive
euthanasia. The broad construal is more widely used and is adopted in this research as
well, because of its employment in Rachelss works; although the researcher agrees
only with the narrow construal of euthanasia.
Euthanasia is a general term and there are few widely used corresponding terms.
These terms are definitions which decipher the meaning of different types of euthanasia.
Among these terms are widely used active and passive euthanasia. Active euthanasia or
euthanasia by action, also called mercy killing or positive euthanasia, is intentionally
causing a persons death by performing an action such as by giving a lethal injection.
Passive euthanasia or euthanasia by omission, also called negative euthanasia, is the
withholding or withdrawing the unnecessary and extraordinary medical treatment.
Rachels (1983) widens the definition of active euthanasia; according to him it refers to
the intentional and /or direct killing of an innocent human life either by that person,
suicide, or by another, assisted suicide (p.19). Gifford (1993) describes the difference
between the two types of euthanasia: Passive euthanasia involves allowing a patient to
die by removing her from artificial life support systems such as respirators and feeding
Introduction 6
tubes or simply discontinuing medical treatments necessary to sustain life. Active
euthanasia, by contrast, involves positive steps to end the life of a patient, typically by
lethal injection (p. 1546).
Active and passive euthanasia are the main categories, however, they are further
classified depending on the relevant factors or circumstances such as Voluntary,
Involuntary, and Non-voluntary euthanasia. The American Medical Associations,
AMAs, Council on Ethical and Judicial Affairs (1992) makes three distinctions
concerning consent and euthanasia as follows:
Voluntary euthanasia is euthanasia that is provided to a competent person on
his or her informed request. Non-voluntary euthanasia is the provision of
euthanasia to an incompetent person according to a surrogates decision.
Involuntary euthanasia is euthanasia performed without a competent persons
consent. (p. 2230)
These distinctions while combined with the active / passive distinction form six
different types of euthanasia: voluntary active, voluntary passive, non-voluntary active,
non-voluntary passive, involuntary active and involuntary passive. Closely related to
euthanasia are terms such as assisted suicide and physician assisted suicide. Assisted
suicide is when someone provides an individual with the information, guidance, and
means to take his or her own life with the intention that they will be used for this
purpose. Likewise, when it is a doctor who helps another person to kill himself or
herself it is called physician assisted suicide. However, there is a sharp difference
between euthanasia and physician assisted suicide. The AMAs Council on Ethical and
Introduction 7
Judicial Affairs (1992) states as follows:
Euthanasia and assisted suicide differ in the degree of physician participation.
Euthanasia entails a physician performing the immediate life ending action
(e.g., administering a lethal injection). Assisted suicide occurs when a
physician facilitates a patients death by providing the necessary means and /or
information to enable the patient to perform the life-ending act (e.g., the
physician provides sleeping pills and information about the lethal dose, while
aware that the patient may commit suicide). (p. 2231)
The researcher holds that euthanasia is only the narrow construal of euthanasia;
that is active euthanasia alone. The researchers contention is that since euthanasia
enfolds the meaning of intentional, mercy killing in what has come to be known as
passive euthanasia intentional killing is not part of the withholding or withdrawing the
unnecessary and extraordinary medical treatment. The confusion between suicide,
assisted suicide, physician assisted suicide, and euthanasia also deserves some analysis.
This confusion of terms is very widespread in the well circulated literature on
euthanasia; most importantly, Rachels, as noted earlier, confuses these terms too, his
definition of active euthanasia includes mercy killing, suicide, assisted suicide and
physician assisted suicide (Rachels, 1983, p.19).
The researcher holds that passive euthanasia, suicide, assisted suicide, and
physician assisted suicide are not euthanasia; only active euthanasia mercy killing is
euthanasia. The researchers definitional understanding is in consistency with AMAs
definitions. Therefore, the researchers definition of euthanasia is: intentionally causing

Introduction 8
a terminally ill persons death for the reasons of mercy . The analysis of the definition is
as follows:
Person X commits euthanasia on Person Y if
i. X takes the life of Y
ii. Y is suffering from a disease or injury from which Y is not expected to
recover
iii. the action of X's taking Y's life is intentional
The definition includes: voluntary, non-voluntary, and involuntary active
euthanasia. The definition excludes: suicide, assisted suicide, physician-assisted
suicide and passive euthanasia.
The definition is based on the facts that: (1) the death is caused by an agent
(human) instead of the subject (the patient), (2) the causing of death is intentional (3)
the death is caused either by the request of the subject or the state of the subject to make
it different from a pure homicide (4) the death is caused by commission or action and (5)
the subject is terminally ill. Therefore, euthanasia as defined above will include only
active euthanasia.
The reasons behind not considering passive euthanasia as euthanasia is due to:
(1) the death is natural, and not artificial (2) the death is not caused by action of any
agent. The suicide, assisted suicide, and physician assisted suicide are excluded due to:
(1) the death is not caused by an agent other than the subject. The very integral factor of
the notion of euthanasia is being killed by some agent (person) instead of the subject.
Introduction 9
After definitional analysis of euthanasia, a brief historical sketch of euthanasia
and its development is noteworthy to put the intellectual threads on the issue together.
The problem of euthanasia has a long history of philosophical discussion. However,
most of the discussion revolves around the issue of suicide. The discussion of suicide
itself could be related to problem of euthanasia since both of them aim at termination of
life. The researcher thinks that suicide is a general concept whereas euthanasia is a
special case. Euthanasia is about a terminally ill person whereas suicide enfolds various
possibilities and motives for opting termination of life. Therefore, the relation between
suicide and euthanasia is a relation between universal and particular. However, lines of
distinction could be drawn between suicide and euthanasia. Euthanasiait might be
claimedis an alleged solution for the ills of dying, whereas suicide is an alleged cure
for the ills of living ( Donnelly, John, 1998, p.10). On the other hand, wishing death
and planning the steps toward ending a life is shared by both euthanasia and suicide.
The quality of life and its intrinsic value remain central in both euthanasia and suicide.
Both these issues share many common threads which bring suicide and euthanasia on
parallels, if not completely, nevertheless, partially. Therefore, in the historical sketch of
the problem the distinction between suicide and euthanasia is intentionally considered
irrelevant because suicide is general and in principle it includes euthanasia. And
Indeed, to justify either one, suicide or mercy killing, is to justify the other (Fletcher
1987 / 1989, p. 91).
The intellectual and academic debate of euthanasia draws on history of western
philosophy ranging from the ancient to contemporary time. The expounding
philosophers on the issue could be categorized into three groups: opponents,

Introduction 10
proponents, and moderates. Opponents such as Hippocrates, Aquinas, Kant, and Hegel
claim that suicide is always morally wrong; proponents include Epicurus, Seneca,
Montaigne, Montesquieu, Holbach, Diderot, Rousseau, Voltaire, Schopenhauer, and
Nietzsche; and moderates such as Plato and Hume hold that suicide is both moral and
immoral depending on the motivating factors and the contexts. Therefore, the
following account will be a precise literature review of the case with some elaborations
wherever necessary.
In ancient Greece, euthanasia was not practiced, and suicide was generally
disfavored. In fact, Athenian law treated suicide as a crime, punishing the guilty by
amputating the corpse's right hand and denying traditional burial rituals (Mair, 2007,
pp. 26-30). However, Alvarez (1971) suggests that although suicide was taboo, the
Greeks tolerated suicide in some circumstances (p.58). Meanwhile, Hippocrates
(460-370 BCE), the ancient Greek physician, strongly opposed euthanasia, assisted
suicide, and physician assisted suicide. Wording of his famous oath attests his position:
I will not prescribe a deadly drug to please someone, nor give advice that may cause
his death (Hippocrates, 2005). Accordingly, Hippocrates oath has since then
normatively defined the medical profession as life saving. Some Greek philosophers,
such as, Plato did add three exceptions to the immorality of suicide. According to him,
suicide might be permissible when compelled by (1) judicial order, (2) excruciating
misfortune, or (3) moral disgrace (Plato, 1980, p. 268). However, Platos exceptions do
not apply to permissibility of active euthanasia. Nevertheless, Plato seems to be in
favor of passive euthanasia; in The Republic, Plato argued that patients should be
permitted to refuse intrusive medical treatments that may lengthen their lives, while
Introduction 11
making them very unpleasant and useless to the state (Plato, 1991, p. 84-89). On the
contrary, Aristotle believed that suicide was unjust under all circumstances, because it
deprived the community of a citizen (Aristotle, 1999, p. 84). Regardless of Aristotle,
the Stoics focused more strongly on the welfare of the individual than on the
community. Roman Stoics such as Annaeus Seneca (4 B.C.E.-C.E. 65) argued that the
individual should have broad discretion to end his or her own life. Seneca emphasizes
considerations of quality of life over mere existence and recommends dying well as an
escape from the ills of living (Seneca. (1917/ 1998, pp. 35-39).
In medieval times, Christian, Jewish, and Muslim philosophers opposed active
euthanasia, although the Christian Church has always accepted passive euthanasia and
condemned active euthanasia. The most influential and scholastic defense of Catholic
position comes in the thirteenth century by Thomas Aquinas (1225-1274). Aquinas
gave three highly influential arguments for the immorality of suicide: (1) it contravenes
ones duty to oneself and the natural inclination of self-perpetuation; (2) it injures other
people and the community of which the individual is a part; and (3) it violates Gods
authority over life, which is Gods gift (Aquinas, 1947, 11, 11, Q.64, Art.5.). This
position shaped attitudes about suicide that prevailed from the Middle Ages through
the Renaissance and Reformation. By the sixteenth century, philosophers began to
challenge the generally accepted religious condemnation of suicide. Michel de
Montaigne, a sixteenth-century philosopher, argued that suicide was not a question of
Christian belief but a matter of personal choice (Ferngren, 1989, pp. 159-61).
During the Renaissance, Thomas More (1478-1535) defended euthanasia;
according to him when a patient has a torturous and incurable illness, the patient has the
Introduction 12
option to die, either through starvation or opium (More, 1999, p. 22.). In the eighteenth
century, David Hume (1711-1776) made the first unapologetic defense of the moral
permissibility of suicide on grounds of individual autonomy and social benefit. Humes
defense is utilitarian and he disagrees with the arguments of Aquinas. However, Hume
did not advocate that all suicides are justified, but argued that when life is most plagued
by suffering, suicide is most acceptable (Hume, 2004, p.2-8). Other philosophers of the
Age of Reason, such as John Locke and Immanuel Kant, opposed suicide. Locke
argued that life, like liberty, represents an inalienable right, which cannot be taken from,
or given away by, an individual (Ferngren, 1989, pp. 173-75). For Kant (1724-1804),
suicide was a paradigmatic example of an action that violates moral responsibility.
Kant believed that the proper end of rational beings requires self-preservation, and that
suicide would therefore be inconsistent with the fundamental value of human life (Kant,
1785).
The nineteenth and early twentieth centuries brought several developments that,
while not explicitly philosophical, have shaped philosophical thought about suicide.
Michael Cholbi (2004) points out these developments: (1) the emergence of a
Romantic idealized script for suicide in novels by Rousseau, Goethe, and Flaubert,
according to which suicide was the inevitable response of a misunderstood and
anguished soul jilted by love or shunned by society (Lieberman 2003.); (2) the
recognition of psychiatry as an autonomous discipline capable of diagnosing and
treating the ailments responsible for suicide; and (3) the work of sociologists such as
Durkheim and Laplace, who viewed suicide as a social ill reflecting widespread
alienation, anomie, and other attitudinal byproducts of modernity. Moreover, suicide

Introduction 13
was of central concern for the twentieth century existentialists, who saw the choice to
take one's life as impressed upon us by our experience of the absurdity or
meaninglessness of the world and of human endeavor (Section 2.3, para. 9-10).
The late twentieth century represents two aspects of the issue of suicide. The
debate becomes divided into two separate discourses: suicide and euthanasia. Both
these subjects became separate along with their subject matter and arguments; although
there is unavoidable overlap between them. The nature of euthanasia becomes special
because it touches medical profession and debate over rights and duties. Thus
euthanasia widely becomes interdisciplinary and subject of legal analysis in various
countries.
Tracking the developments regarding euthanasia in twentieth century, the
societies which advance the cause of positive euthanasia were founded in 1935 in
England and in 1938 in the United States. Since 1937 assisted suicide has been legal in
Switzerland as long as the person who assists has no personal motive or gain. The
Second World War changed the atmosphere of discussion on euthanasia. In 1939, the
Nazis practiced euthanasia in various specialized medicine departments; the victims
were gassed or poisoned. After the Second World War, the debate became silent for a
long period until the 1970s. In the 1970s and early 1980s, the discussion on euthanasia
became a more extensive academic and public debate. This is the same period when
James Rachels wrote his major works. The Northern Territory of Australia was the first
state to pass laws allowing a physician to end the life of a terminally ill patient, but just
6 months after the first death under the passed act, the act was overturned by the
Australian Federal Senate. On 27 October 1997, the state of Oregon legalized

Introduction 14
physician-assisted suicide. In 1993, the Netherlands decriminalized, under a set of
restricted conditions, voluntary active euthanasia, essentially, physician-assisted
suicide, for the terminally ill, and in 2002 the country legalized physician-assisted
suicide if voluntarily requested by seriously ill patients who face ongoing suffering.
Belgium has also legalized euthanasia since 2002 for certain patients who have
requested it. Besides these developments, the discourse on euthanasia is continuously
in progress attracting attention from experts of various disciplines and likewise the
issue has been subjected to public opinion polls time to time.
Apart from every sort of disciplinary perspective on the issue of euthanasia, the
issue in its essential relation is practically connected with medicine. The issue of
euthanasia has brought the medical profession in question. The traditional and common
sense understanding of the profession is life saving. However, the defenders of active
euthanasia suggest the redefining the profession not only as life saving, but also life
taking. From that point on, the issue touched the legality of practicing euthanasia on the
grounds of autonomy, rights, and duties. Autonomy, not only of patients, but of doctors
too. And duty, not only of doctors to kill a patient, but of patients too in a
psychologically shaped euthanasian culture. And most of all, the status of rights of a
patient to claim such a right. Due to the crucial touch of euthanasia to medical
profession, on December 4, 1973, the House of Delegates of the American Medical
Association (AMA) asserted its position on the issue of euthanasia as follows:
The intentional termination of the life of one human being by
another--mercy killing--is contrary to that for which the medical profession
stands and is contrary to the policy of the American Medical Association.

Introduction 15
The cessation of the employment of extraordinary means to prolong the life
of the body when there is irrefutable evidence that biological death is
imminent is the decision of the patient and/or his immediate family. The
advice and judgment of the physician should be freely available to the
patient and /or his immediate family. (as cited in Rachels, 1975 / 1994a, pp.
112-113)
The above statement generated a prompt debate on the issue both in the field of
ethics and legal theory. The AMAs position on the issue came to be named as
conventional doctrine on euthanasia (CDE) or traditional view. It is important to
mention that AMAs position, although adopted in the United States, its message
resonates globally in the forums and associations that are concerned with the issue. In
accordance with the AMAs position, the World Medical Association's Declaration on
Euthanasia, adopted by the 38th World Medical Assembly, Madrid, Spain, in October
1987, states:
Euthanasia, that is the act of deliberately ending the life of a patient, even at
the patient's own request or at the request of close relatives, is unethical. This
does not prevent the physician from respecting the desire of a patient to allow
the natural process of death to follow its course in the terminal phase of
sickness. (World Medical Association, 2002, Section, 1)
James Rachels (1941-2003), the distinguished American moral philosopher,
criticized the AMAs statement just after its publication; he is the most outspoken
rebutter of the position. His approach to euthanasia came to be known as libertarian

Introduction 16
view. Rachels was born in Columbus; he received his Ph.D. in 1967 from the
University of North Carolina. He taught at the University of Richmond, New York
University, the University of Miami, Duke University, and the University of Alabama
at Birmingham. 1971 saw the publication of his groundbreaking anthology Moral
Problems. In 1975, Rachels wrote "Active and Passive Euthanasia, originally
appearing in the New England Journal of Medicine, this essay has been reprinted 300
times. The End of Life (1986) broadened and deepened his ideas on euthanasia. His
Created from Animals (1990) argued that a Darwinian world-view has widespread
philosophical implications, including drastic implications for our treatment of
nonhuman animals. Can Ethics Provide Answers? (1997) was Rachelss first collection
of papers; The Legacy of Socrates (2007) was his second. Rachelss textbook, The
Elements of Moral Philosophy, is currently the best-selling book in philosophy. Shortly
before being diagnosed with cancer, Rachels finished Problems from Philosophy, an
introduction to his subject, published posthumously. Over his career, Rachels wrote 5
books and 86 essays, edited 7 books and gave about 275 professional lectures (Official
Website of James Rachels, n.d. Brief Biography, para.1-2).
In criticizing the AMAs position on euthanasia, Rachelss first attempt was to
show that there is morally no difference between active and passive euthanasia, and
where passive euthanasia is appropriate, active should be allowed too; he elaborated on
the idea in his article "Active and Passive Euthanasia" (1975/ 1994a). He challenged
the conventional doctrine of euthanasia (CDE) for several reasons: active euthanasia is
in many cases more humane that passive euthanasia; the conventional doctrine leads to
decisions concerning life and death on irrelevant grounds; the doctrine rests on a
Introduction 17
distinction between killing and letting die that itself has no moral importance; and the
most common arguments in favor of the doctrine are invalid. Secondly, Rachels in
More Impertinent Distinctions and a Defense of Active Euthanasia" (1981/ 1994b)
explicitly supported active euthanasia. Rachels stated two main arguments: the first is
the argument from mercy; the second is the argument from the best interests and the
golden rule. He added one more argument for the legalization of active euthanasia
based on the right to liberty and autonomy. (Rachels, 1983, p.19). Thirdly, Rachels is a
moral, utilitarian philosopher; while elaborating his thought on euthanasia, he refers
directly and indirectly to his conceptual framework which permeates all of his
arguments. Rachelss conceptual framework deals with distinctions such as biological
and biographical life, killing and letting die; and ordinary and extraordinary medical
treatment. In addition to that, in his rejoinder article An Argument against Legalizing
Active Euthanasia: The Slippery Slope (2003), Rachels provided the detailed
framework on the legislation for active euthanasia. The chapter two of this research
deals with the abovementioned ideas of Rachels in a detailed form. The ideas are
grouped in three categories respectively: conceptual framework, arguments for
absolution of the distinction between active and passive euthanasia, and arguments for
active euthanasia including the proposal on legislation for active euthanasia
respectively.
The criticism of Rachelss thought on euthanasia is detailed in chapter three.
The criticism is conceptual and normative. The arguments developed by Rachels are
addressed. The chapter analyzes firstly, the conceptual framework of Rachels and
demonstrate its inadequacy on conceptual and practical basis; secondly, it demonstrates

Introduction 18
the theoretical problems in Rachelss arguments which attempt to prove the distinction
between active and passive euthanasia is morally absurd, therefore, the criticism leads
to invalidity of the active euthanasia. And thirdly, it criticizes Rachelss arguments for
active euthanasia by showing their weaknesses which affect their soundness. In
addition, the researcher also shows the problems in Rachelss proposal on the
legalization of active euthanasia which renders his proposal problematic and
impractical. And, lastly, the researcher debates that there is only one type of euthanasia
which is active euthanasia and which ought to be rejected, due to its unjustifiability.
Finally, the researcher shows that Rachelss active and passive dichotomy is a false
dichotomy.
The chapter four summarizes the research and concludes the findings by
establishing the thesis statement and furthermore mentions also the further research
and recommendations.
1.2. Thesis Statement
James Rachelss defense of active euthanasia is conceptually, theoretically,
practically, and normatively unjustifiable.
1.3. Objectives
1.3.1. To provide a detailed exposition of the issue of euthanasia. The exposition
includes the explanation of the terms and definitions, the historical background of the
issue, and the current debate on the issue.
1.3.2. To provide the descriptive exposition of James Rachelss view on euthanasia

Introduction 19
1.3.3. To provide a critical study of Rachelss view on euthanasia.
1.3.4. To provide the justification of the thesis statement.
1. 4. Limitation and Methodology of the Research
The limitations on the research are as follows:
1.4.1. This is a focused research on James Rachelss defense for active euthanasia. The
research is therefore basically confined to his works on the issue.
1.4.2. This research will address only those arguments which are explicitly detailed in
the works of Rachels. It includes the arguments which he develops, supports, or refutes.
1.4.3. The approach of argumentation is secular. Therefore, religious arguments are not
included. However, rational arguments, though, labeled or proclaimed as religious will
be included.
1.4.4. The nature of the research methodology is on parallels with Rachelss
methodology which is conceptual, practical, theoretical and normative.
1.4.5. The methodology employed will combine conceptual analysis, criticism, and
argumentation. Firstly, the analysis and presentation of Rachelss thought will be
undertaken. His arguments and position will be made clear. And secondly criticism of
his arguments and position will be undertaken by two ways: by finding problems within
his thought and by arguing against his position. The debate of the issue is not confined
to any ethical criteria or to any ethical theory among normative ethical theories, rather
the issue is tackled by independent arguments.

Introduction 20
1.4.6. This research is not meant to reach on conclusions on the issue of euthanasia, but
to attempt to reach on conclusions on Rachelss defense of active euthanasia.

CHAPTER TWO
Exposition of Rachelss Thought on Euthanasia
2.1. Introduction
James Rachelss thought on euthanasia begins from his counter and refuting
responses to the American Medical Associations (AMAs) statement, which stated its
position on euthanasia by endorsing, according to Rachels, the traditional doctrine of
euthanasia (TDE) or conventional doctrine of euthanasia (CDE). Rachelss first attempt
was to show that there is morally no difference between active and passive euthanasia.
In his article "Active and Passive Euthanasia" (1975/ 1994a), which appeared in The
New England Journal of Medicine, he did not argue in support of active euthanasia
explicitly. His main attempt, in the article, was to show that there is no moral difference
between active and passive euthanasia, and where passive euthanasia is appropriate,
active should be allowed too. However, in his rejoinder essay, "More Impertinent
Distinctions and a Defense of Active Euthanasia" (1981/ 1994b), he explicitly
supported active euthanasia in an argumentative manner. Both the abovementioned
articles, and the reproduction of the same thought in his numerous articles (1977, 1979a,
1979b, 1980, 1981a, 1981b, 1984, 1993, 2001, & 2002), contained the most of the
conceptual framework which Rachels uses in his works. Finally, in The End of Life:
Euthanasia and Morality (1986b), Rachels gave a systematic shape to his ideas and
elaborated comprehensively on all aspects of the related issues. Rachelss
abovementioned works suggested the moral and practical permissibility of voluntary
active euthanasia to medical doctors and judicial courts. In addition to that, in his
Exposition of Rachelss Thought on Euthanasia 22
rejoinder article An Argument against Legalizing Active Euthanasia: The Slippery
Slope (2003), Rachels provided the detailed framework for the legalization of active
euthanasia.
The arrangement and ordering of Rachelss ideas in this chapter is different
from the chronological order of his writings; due to need of understanding his thought
in a logical order for the convenience of comprehension and criticism. Therefore, his
conceptual framework is sketched firstly; his arguments showing the morally absurd
distinction between active and passive euthanasia are elaborated secondly; thirdly his
arguments in favor of active euthanasia are explained with details; and finally his
proposal on legalizing active euthanasia is stated precisely. Meanwhile, his responses
to rejoinders are mentioned during the course of explicating his arguments. The best
part of his instant responses to rejoinders, during his lifetime, is that they have served a
stimulus to Rachels to speak out more clearly on many related issues. For example, in
his article More Impertinent Distinctions and a Defense of Active Euthanasia (1981/
1994b) which is partially a response to Thomas D. Sullivans article, Active and
passive euthanasia: An impertinent distinction? (1977/1994a), Rachels, further
explains notions such as intentionality; ordinary and extraordinary means of treatment;
and arguments which support active euthanasia.
Therefore, the chapter is based on three areas: conceptual framework,
arguments for absolution of the distinction between active and passive euthanasia, and
arguments for active euthanasia including the proposal on legalization of active
euthanasia respectively.
2.2. Rachelss Euthanasian Conceptual Framework
Rachels is a moral, utilitarian philosopher; while elaborating his thought on
euthanasia, he refers directly and indirectly to his conceptual framework which, in fact,
permeates all of his arguments. In brief, Rachelss conceptual framework comprises of
distinctions such as biological and biographical life; killing and letting die; and
ordinary and extraordinary medical treatment. The most of these distinctions make
sense both theoretically and practically only if the passive euthanasia is accepted as
given and permissible. On the whole, Rachels shows that biographical life is morally
relevant whereas mere biological life is not so; there is morally no difference between
killing and letting die ; and the ordinary and extraordinary distinction is senseless. The
following part of the chapter precisely explicates this conceptual framework.
2.2.1. Biological Life and Biographical Life
Rachels makes a distinction between biological and biographical life; his
support for active euthanasia is largely based on this distinction. The biological life is
being a living being. Whereas, according to Rachels, biographical life is the sum of
one's aspirations, decisions, activities, projects, and human relationships (Rachels,
1986b, p. 526, 33, 35, 38, 47, 49-59, 65, 76, 85). Rachels claims that the mere fact that
something has biological life, whether human or nonhuman is relatively unimportant
from an ethical point of view. What is important, according to Rachels, is that someone
has biographical life. The facts of a person's biographical life are those of that person's
history and character. They are the interests that are important and worthwhile from the
point of view of the person himself or herself. The value of one's biographical life is the
value it has for that person, and something has value if its loss would harm that person
(Rachels, 1986b, p. 38). The distinction is such a drastic that it, in principle, does not
support only voluntary active euthanasia, but also non-voluntary and involuntary,
though Rachels would finally agree on voluntary active euthanasia only.
The significant implication of the above view entails that certain persons
without a prospect for biographical life, and certain terminally ill patients, are of little
intrinsic concern, morally speaking. Though they may be alive in the biological sense,
they are not alive in the biographical sense. And the latter is what is relevant to morality.
Therefore, the distinction gives a considerable and decisive weight to Rachelss
position, that such persons, who are biologically alive but biographically without any
prospect, are subjects of active euthanasia.
2.2.2. Killing and Letting Die
Rachels argues that there is morally no distinction between killing someone and
letting someone die. Furthermore, he argues that intentions are not relevant to moral
judgments. The implication of the distinction is related to the active/passive dichotomy.
According to Rachels, active euthanasia involves actually killing the sick individual,
whereas passive euthanasia involves simply letting the person die. Rachels, by applying
the above concept, attempts to show that the active / passive dichotomy is a distinction
without difference. To demonstrate the distinction, he forwards a main argument: the
bare difference argument or equivalence thesis. The implication, which follows from
the argument, is that the cases where passive euthanasia is permissible are also the cases
where active euthanasia should be permissible too.

Rachels, while explaining the above distinction, sets up two cases that are
supposed to be exactly alike except that one involves killing and the other involves
letting die. The cases are hypothetical, which involve two characters: Smith and Jones.
Smith stands to gain a large inheritance if anything should happen to his six-year-old
cousin. One evening while the child is taking his bath, Smith sneaks into the bathroom
and drowns the child, and then arranges things so that it will look like an accident. As a
result, Smith gets his inheritance without getting caught. On the other hand, Jones also
stands to gain if anything should happen to his six-year-old cousin. Like Smith, Jones
sneaks in planning to drown the child in his bath. However, just as he enters the
bathroom Jones sees the child slip, hit his head, and fall face-down in the water. Jones is
delighted; he stands by; ready to push the child's head back under if necessary, but it is
not necessary. With only a little thrashing about, the child drowns all by himself,
accidentally, as Jones watches and does nothing. As a result, Jones gets his inheritance
without facing any blame (Rachels, 1975/ 1994a, pp. 115-116; 1986b, p. 112).
According to Rachels, neither man behaved better even though Smith killed the
child and Jones merely let the child die. Both acted from the same motive, personal gain,
and the results were identical, death. Thus according to Rachels, the only difference
between the two cases is killing versus letting die, and since the cases are morally
equivalent, this distinction is morally irrelevant. Therefore, the above hypothetical case,
according to Rachels, makes the distinction between active and passive euthanasia
absurd. They are morally the same; therefore, where letting die is permissible,
killing should be allowed too. The other meaning could be if killing is not allowed,
letting die should be prohibited too; but that is not what Rachels aims at, he would
rather, support killing in the case.
The bare difference argument, as illustrated above, which shows that there is no
difference between killing and letting die, faced a response from Thomas D. Sullivan.
In summary, Thomas D. Sullivans point is that the difference is due to difference in
intentions (1977/1994a). He claims that in active euthanasia the doctor intends to kill,
whereas in passive euthanasia the intent is not involved. Rachels attempts to refute the
claim, and while discrediting Sullivans position, Rachels concludes that rightness or
wrongness of an act is determined by the reasons for it or against it, and intention as
such has morally no importance. Rachels further adds that if a person is trying to decide
whether treatment should be continued; he should think about the reasons for and
against it. Rachels responds that on the one hand, if treatment is ceased the terminally
ill person will die very soon, and on the other hand, the person will die eventually
anyway, even if treatment is continued. He adds that, moreover, if the persons life is
prolonged, its suffering will be prolonged as well, and the medical resources used will
be unavailable to others who would have a better chance of a satisfactory cure.
In light of all this, Rachels concludes, you may well decide against continued
treatment. Rachels draws attention to the fact that there is no mention here of anybody's
intentions. Rachels emphasizes that the intention you would have, if you decided to
cease treatment, is not one of the things you need to consider. It is not among the
reasons either for or against the action. That is why it is irrelevant to determining
whether the action is right (Rachels, 1981/ 1994b, p.143). Rachels further states that a
person's intention is relevant to an assessment of his character; intentions are relevant
for thinking a person a good or a bad person. But, according to Rachels, the intention is
not relevant to determining whether the act itself is morally right; according to Rachels,
the rightness of the act must be decided on the basis of the objective reasons for or
against it. He, therefore, concludes that the traditional view is mistaken on this point
(Rachels, 1981/ 1994b, p.143).
2.2.3. Ordinary and Extraordinary Means of Treatment
Rachels, while attempting to find the flaws in the AMAs statement, criticizes
the statement which states that life sustaining treatment may sometimes be stopped if
the means of treatment are "extraordinary"; with the implication that "ordinary" means
of treatment may not be withheld (Rachels, 1981/ 1994b, p.143). The distinction
between ordinary and extraordinary treatments is crucial and Thomas D. Sullivan
reemphasizes and reaffirms its importance in a rejoinder to Rachels (Sullivan, 1994b).
Responding to the above distinction as held in the traditional view, Rachels
states that, however, upon reflection it is clear that it is sometimes permissible to omit
even very ordinary sorts of treatments. (Rachels, 1981/ 1994b, p.143). Rachels
debates the definitions of ordinary and extraordinary means of treatment which are
briefly mentioned in the AMAs statement and are well extended by Thomas D.
Sullivan. Rachels, therefore, makes his objections to the Sullivans understanding of
the distinction as a representing commentary of the AMAs statement.
Thomas D. Sullivan in fact bases his understanding of the distinction on the
following definitions of Paul Ramsey:
Ordinary means of preserving life are all medicines, treatments, and
operations, which offer a reasonable hope of benefit for the patient and
which can be obtained and used without excessive expense, pain, and other
inconveniences. Extraordinary means of preserving life are all those
medicines, treatments, and operations which cannot be obtained without
excessive expense, pain, or other inconvenience, or which, if used, would
not offer a reasonable hope of benefit. (as cited in Sullivan, 1994a, p. 135)
Rachels criticizes the above definitions and claims that they are useless. He
states two problems regarding the distinction which, according to his understanding,
render the distinction senseless. Rachels takes the definitional analysis of the
distinction.
Rachels, firstly criticizes the way the word "excessive" functions in these
definitions. He states that it is said that a treatment is extraordinary if it cannot be
obtained without excessive expense or pain. He, therefore, poses the question: when is
an expense "excessive"? He adds, is a cost of $10,000 excessive? If it would save the
life of a young woman and restore her to perfect health, $10,000 does not seem
excessive. But if it would only prolong the life of Ramsey's cancer-stricken diabetic a
short while, perhaps $10,000 is excessive. Rachels concludes that the point is not
merely that what is excessive because it changes from case to case; what is excessive
depends on whether it would be a good thing for the life in question to be prolonged
(Rachels, 1981/ 1994b, p. 144).
Secondly, Rachels turns to the use of the word "benefit" in the definitions. He
states that it is said that ordinary treatments offer a reasonable hope of benefit for the
patient; and that treatments are extraordinary if they will not benefit the patient
(Rachels, 1981/ 1994b, p. 145). Rachels responds to the above by saying that how do
we tell if a treatment will benefit the patient? He reminds that we are talking about life
prolonging treatments; the "benefit," if any, is the continuation of life. Whether
continued life is a benefit depends on the details of the particular case. For a person
with a painful terminal illness, a temporarily continued life may not be a benefit. For a
person in irreversible coma, such as Karen Quinlan, continued biological existence is
almost certainly not a benefit. On the other hand, for a person who can be cured and
resume a normal life, life-sustaining treatment definitely is a benefit. Therefore he
concludes that in order to decide whether life-sustaining treatment is a benefit we must
first decide whether it would be a good thing for the life in question to be prolonged
(Rachels, 1981/ 1994b, p. 145).
After making above two objections, Rachels concludes that these definitions
do not mark out a distinction that can be used to help us decide when treatment may be
omitted. Rachels states that we cannot, by using the definitions, identify which
treatments are extraordinary, and then use that information to determine whether the
treatment may be omitted. For the definitions, Rachels points out, require that we must
already have decided the moral questions of life and death before we can answer the
question of which treatments are extraordinary (Rachels, 1981/ 1994b, p. 145) Rachels
concludes his debate as follows:
If we apply the distinction in a straightforward, commonsense way, the
traditional doctrine is false, for it is clear that it is sometimes permissible to
omit ordinary treatments. On the other hand, if we define the terms as
suggested by Ramsey and Sullivan, the distinction is useless in practical
decision making. In either case, the distinction provides no help in

formulating an acceptable ethic of letting die. (Rachels, 1981/ 1994b, p.
145)
The above mentioned conceptual framework which sets distinctions is present
almost in every argument of Rachels. The following part of the chapter presents
Rachels arguments against traditional doctrine on euthanasia (TDE), which makes the
distinction between active and passive euthanasia; Rachels argues that the distinction is
morally absurd and , therefore, where passive euthanasia is allowed, active euthanasia
should be permitted as well.
2.3. Rachelss Arguments against Traditional Doctrine on Euthanasia (TDE)
Rachels argues against the traditional doctrine on euthanasia, which is also
called as conventional doctrine on euthanasia (CDE) or standard view; which makes a
distinction between active and passive euthanasia. This view is, according to Rachels,
endorsed by the American Medical Association. According to the conventional view,
passive euthanasia is sometimes permitted, whereas active euthanasia is prohibited.
Rachels in arguing against the conventional view refers to the statements made by the
American Medical Association which states:
The intentional termination of the life of one human being by
another--mercy killing--is contrary to that for which the medical
profession stands and is contrary to the policy of the American Medical
Association. The cessation of the employment of extraordinary means to
prolong the life of the body when there is irrefutable evidence that
biological death is imminent is the decision of the patient and/or his

immediate family. The advice and judgment of the physician should be
freely available to the patient and/or his immediate family. (as cited in
Rachels, 1975 / 1994a, pp. 112-113)
The AMA statement does not include terminology such as active and passive
euthanasia. However, the way the statement is laid out refers to two categories: (1)
termination of extraordinary medical treatment in face of irrefutable evidence that
biological death is imminent and patients consent is favorable, and (2) the prohibition
of intentional termination of the life of one human being by another. The meaning of
the statement is matter of interpretation. The researcher holds that the statement does
refer to active euthanasia and prohibits it and it does not refer to passive euthanasia as
understood by Rachels. Rather, the statement refers to the cessation of the employment
of extraordinary means to prolong the life. However, the passive euthanasia is used for
convenience in this chapter due to Rachelss formulation of the statement.
Rachelss position against CDE is briefly summarized in the abstract of his
famous article, Active and Passive Euthanasia as follow:
The traditional distinction between active and passive euthanasia requires
critical analysis. The conventional doctrine is that there is such an important
moral difference between the two that, although the latter is sometimes
permissible, the former is always forbidden. This doctrine may be challenged
for several reasons. First of all, active euthanasia is in many cases more
humane that passive euthanasia. Secondly, the conventional doctrine leads to
decisions concerning life and death on irrelevant grounds. Thirdly, the

doctrine rests on a distinction between killing and letting die that itself has no
moral importance. Fourthly, the most common arguments in favor of the
doctrine are invalid. I therefore suggest that the America Medical Association
policy statement that endorses this doctrine is unsound. (Rachels,
1975/1994a, p.112)
Rachels in the following arguments attempts to show that the conventional
view which permits passive euthanasia, in fact, leads to permissibility of active
euthanasia. The ultimate goal of his arguments is that there is no moral difference
between active and passive euthanasia, and where passive euthanasia is permitted,
active ought to be permitted, but preferred too. In arguing against the positions taken in
the AMAs statement, Rachels proposes four challenges as follows:
2.3.1. Often Active Euthanasia Seems More Humane Than Passive
Rachels claims that active euthanasia seems more humane than passive
euthanasia. Therefore, active euthanasia should not be only permitted but preferred.
Rachels illustrates the above challenge by examples. He gives a few examples of
patients who suffer unbearable pain and, therefore, he suggests that it would be better to
kill such patients for the sake of ending their suffering. Rachels gives an example of a
cancer patient who is dying of incurable cancer of the throat is in terrible pain, which
can no longer be satisfactorily alleviated. He is certain to die within a few days, even if
present treatment is continued, but he does not want to go on living for those days since
the pain is unbearable. So he asks the doctor for an end to it, and his family joins in the
request (Rachels, 1975/ 1994a, p.113).

Rachels considers the choices available in such a case which are: (1) keeping
the patient alive with life-supporting equipment, in that case he will experience a few
more painful months, (2) allowing the patient to die by removing the life-supporting
equipment, instead of months it will be days, then (3) actively ending the patients life,
so that the pain will stop right away. Rachels holds that sometimes doctors and patients
choose option (2), because they want to reduce the patients pain. But, Rachels claims,
option (3) does a much better job at eliminating pain. Rachels gives a few more
examples to show that there are other cases where allowing the patient to die is much
more painful and inhumane than active euthanasia (Rachels, 1975/ 1994a, p.113).
Therefore, in such cases, Rachels claims that active euthanasia seems more humane
than passive euthanasia.
2.3.2. The Conventional View Makes Life-And-Death Decisions on Irrelevant
Grounds
Rachels in support of the claim that the conventional view makes
life-and-death decisions on irrelevant grounds, refers to the case of babies with Down
syndrome. Babies with such kind of disease require a surgical operation. But in certain
cases, parents refrain from having the child operated, as a result of which it will die. He
utilizes a situation in which the child is also born with a congenital defect; in this case it
is an intestinal obstruction. If the parents make the decision to deny operation and
allow the baby to die naturally, the infant will most likely perish from dehydration and
infection. Rachels points out that this painful process could be avoided through active
euthanasia. He calls attention to the cruelty involved in permitting the child to suffer
when there is a lethal injection available that can put him out of his misery. Rachels
draws the attention to the fact that if the lives of these infants are worth living, then
their lives should be preserved. Therefore, he argues that allowing to die and
actively killing would be equally wrong. Rachels concludes:
What makes this situation possible, of course, is the idea that when there is an
intestinal blockage, one can let the baby die, but when there is no such defect
there is nothing that can be done, for one must not kill it. The fact that this
idea leads to such results as deciding life or death on irrelevant grounds is
another good reason why the doctrine should be rejected. (Rachels, 1975/
1994a, p.115)
2.3.3. There is no Moral Difference between Doing and Refraining
Rachels, before attempting to prove that there is no difference between doing and
allowing, explores the commonsense point of view on the issue. He maintains that the
reason why so many people think that there is an important moral difference between
active and passive euthanasia is that they think killing someone is morally worse than
letting someone die. Rachels questions the view and to investigate this issue, he
suggests that two cases may be considered that are exactly alike except that one
involves killing whereas the other involves letting someone die. Rachels gives the
example of Smith and Johns as mentioned earlier under 2.2.2. Killing and Letting Die.
In short, Rachels maintains that there is no moral difference between doing or allowing/
killing or letting die; and intentions are not morally relevant.

2.3.4. Arguments in Favor of the Conventional View do not Work
Rachels claims that the arguments given in favor of conventional view are
unconvincing. He mentions the most common argument in favor of the conventional
view: the important difference between active and passive euthanasia is that, in passive
euthanasia, the doctor does not do anything to bring about the patients death; and the
patient dies of whatever ills already afflict him. In active euthanasia, however the
doctor does something to bring about the patients death: he kills him (Rachels, 1975/
1994a, p.117 ).
Rachels responses to the above argument; he maintains that of course, one can
be held responsible for something that one does not do. Rachels comments that it is not
exactly correct to say that in passive euthanasia the doctor does nothing, for he does do
one thing that is very important: he lets the patient die. Rachels states that the decision
to let a patient die is subject to moral appraisal in the same way that a decision to kill
him would be subject to moral appraisal: it may be assessed as wise or unwise,
compassionate or sadistic, right of wrong. Rachels concludes that if a doctor
deliberately let a patient die who was suffering from a routinely curable illness, the
doctor would certainly be to blame for what he had done, just as he would be to blame
if he had needlessly killed the patient (Rachels, 1975/ 1994a, p.118).
2.4. Rachelss Arguments for Active Euthanasia
Rachelss arguments for active euthanasia are of types. The first type is based
directly on his biological and biographical distinction as elaborated in the conceptual
framework. The second type of arguments, by which he supports active euthanasia, is

the arguments which attempt to establish that the distinction between active euthanasia
and passive euthanasia is morally absurd. Therefore, wherever passive euthanasia is
applicable, active should be permissible as well. This has been shown in the second part
of this chapter. The first two types of arguments can be classified as indirect arguments.
The third type of arguments includes his direct arguments as elaborated in the following
part of the chapter. Rachels states I believe that it [active euthanasia] is morally
justified in some instances and that at least two strong arguments support this position.
The first is the argument from mercy; the second is the argument from the golden rule
(Rachels, 1981/ 1994b, p.146). He adds one more argument for the legalization of
active euthanasia based on the right to liberty (Rachels, 1983). Briefly, this argument
argues that dying people should be free to choose euthanasia as a matter of personal
liberty and autonomy. The arguments are explained in the following part of the chapter.
2.4.1. The Argument from Mercy
Rachels believes that the single most powerful argument in support of
euthanasia is the argument from mercy (Rachels, 1981/ 1994b, p.146 ). He claims that,
it is also an exceptionally simple argument, at least in its main idea, which makes one
uncomplicated point. Rachels explains that terminal patients sometimes suffer pain so
horrible that it is beyond the comprehension of those who have not actually
experienced it. Their suffering can be so terrible that we do not like even to read about it
or think about it; we recoil even from the descriptions of such agony. The argument
from mercy says: euthanasia is justified because it provides an end to that (Rachels,
1981/ 1994b, p.146). Rachels illustrates the above statement by a few examples,
describing the pain of terminally ill patients. The argument is similar to Rachelss first
argument against CDE as mentioned earlier.
2.4.2. The Best Interests and Golden Rule Argument
Rachels while continuing the similar line of thought as in the mercy argument,
attempts to forward two aspects of the same argument separately. The argument is
admixture of the best interests and the golden rule. Rachels starts from the utilitarian
argument in favor of active euthanasia, however, he states that if an argument is based
on the mercy alone on the utilitarian grounds, the argument will be faulty due to the
Principle of Utility as a premise of the argument. Therefore, Rachels tries to avoid such
a problem and comes up with an alternative argument, which is inspired, according to
Rachels, by utilitarianism, but which avoids the difficulties of the pure utilitarian
version of the argument, by not making the Principle of Utility a premise of the
argument. Therefore, Rachels provides the following argument based on doing what is
in everyone's best interests, and he claims that the argument is sound and proves that
active euthanasia can be justified:
1. If an action promotes the best interests of everyone concerned, and violates
no one's rights, then that action is morally acceptable.
2. In at least some cases, active euthanasia promotes the best interests of
everyone concerned and violates no one's rights.
3 Therefore, in at least some cases active euthanasia is morally acceptable.
(Rachels, 1981/ 1994b, p.149-150)
Rachels, after presenting the above argument, states the benefits of employing the
argument in voluntary active euthanasia. His words in their tune and emotion are as
follows:
It would have been in everyone's best interests if active euthanasia had been
employed in the case of Stewart Alsop's friend, Jack [a terminally ill patient
who died in a painful death]. First, and most important, it would have been in
Jack's own interests, since it would have provided him with an easier, better
death, without pain. (Who among us would choose Jack's death, if we had a
choice, rather than a quick painless death?) Second, it would have been in the
best interests of Jack's wife. Her misery, helplessly watching him suffer, must
have been almost equal to his. Third, the hospital staff's best interests would
have been served, since if Jack's dying had not been prolonged, they could
have turned their attention to other patients whom they could have helped.
Fourth, other patients would have benefited since medical resources would no
longer have been used in the sad, pointless maintenance of Jack's physical
existence. Finally, if Jack himself requested to be killed, the act would not
have violated his rights. Considering all this, how can active euthanasia in this
case be wrong? How can it be wrong to do an action that is merciful, that
benefits everyone concerned, and that violates no one's rights? (Rachels,
1981/ 1994b, p.150)
Rachels after presenting the above argument complements the argument by
other argument inspired by the golden rule. Rachelss golden rule argument is actually
the reinforcement of his best interest argument. Rachels states that Immanuel Kant
incorporated the basic idea of the golden rule into his system of ethics. Rachels
discusses the categorical imperative of Kant which says: act only according to that
maxim by which you can at the same time will that it should become a universal law.
Rachels elaborates on the principle: that we should act only on rules that we are
willing to have applied universally; that is, we should behave as we would be willing to
have everyone behave (Rachels, 1981/ 1994b, p.151). Rachels while taking the
careful analysis of the principle states that the basic idea behind the golden rule is a
good one. He points out the following principle:
the basic idea is that moral rules apply impartially to everyone alike; therefore,
you cannot say that you are justified in treating someone else in a certain way
unless you are willing to admit that that person would also be justified in
treating you in that way if your positions were reversed. (Rachels, 1981/ 1994b,
p.151)
Rachels after going into explanatory details about the maxim, ultimately tries to
explain the meaning of the maxim and its relation to the case of euthanasia as follows:
The application of all this to the question of euthanasia is fairly obvious. Each
of us is going to die someday, although most of us do not know when or how.
But suppose you were told that you would die in one of two ways, and you
were asked to choose between them. First, you could die quietly, and without
pain, from a fatal injection. Or second, you could choose to die of an affliction
so painful that for several days before death you would be reduced to howling
like a dog, with your family standing by helplessly, trying to comfort you, but
going through its own psychological hell. It is hard to believe that any sane
person, when confronted by these possibilities, would choose to have a rule

applied that would force upon him or her the second option. And if we would
not want such a rule, which excludes euthanasia, applied to us, then we should
not apply such a rule to others. (Rachels, 1981/ 1994b, p.151-152)
2.4.3. The Argument from Autonomy
Rachelss main arguments in favor of active euthanasia are basically and
essentially based on the consent of the terminally ill patient, that the justification of
such practice is based on the free will and autonomy of the patient and furthermore on
the joint consent of the other parties involved as briefed in the aforementioned
arguments. Therefore, the argument from autonomy in favor of voluntary active
euthanasia stands as the foundation of Rachelss thesis which according to him is based
on two strong arguments, the golden rule and the best interest arguments. The
autonomy argument involves discussions on liberty, rights, self determination and
conception of autonomy itself. Rachels in his works refers to all these concepts to gain
more warranty for his argument.
Rachelss distinction between biological and biographical life shows that
biological life is not the moral issue. Rachels view states that life is not intrinsically
valuable, the moral issue is about having a biographical life (Rachels, 1986b, p. 5).
Biographical life entails that a human being is an autonomous being. Therefore, if a
person autonomously chooses to end his or her life or have someone else assist him or
her in doing so, then it is morally permissible. One should be free to do as one chooses
as long as no harm is done to others. In supporting the position, Rachels develops a
further argument for the legalization of active euthanasia based on the right to liberty.
Briefly, this argument is that dying people should be free to choose euthanasia as a
matter of personal liberty. The supporting argument frequently advanced in support of
legalization of active voluntary euthanasia proceeds by way of analogy to the law of
suicide. Rachels also supports his position by the same argument. The argument begins
with the proposition that since it is not unlawful for a person to commit or attempt to
commit suicide, the law, implicitly at least, recognizes the right of an individual to take
his or her life. From this premise it is argued that if an individual does have the right to
take his or her life, he or she should be able to seek the assistance of others in achieving
this end (Rachels, 1983, p.19 ). It should be noted here that Rachels refers to the
American criminal law. Furthermore, Rachelss arguments such as the golden rule and
the best interest argument are based on the same notion of autonomy that if a terminally
ill patient chooses euthanasia as his best interest, such a patient should be granted his
wish.
2.5. Proposal for Legalization of Active Euthanasia
Rachels proposes what he calls the modest proposal for the legalization of
active euthanasia. Before proposing such a proposal, Rachels makes some elementary
points about American law. He states that according to the American law individuals
charged with a crime have no obligations to prove their innocence. Instead of that, the
burden of proof is on the prosecution, and if the prosecution has not discharged its
obligation to prove guilt, the jury's duty is to acquit the defendant. However, if the
prosecution does establish a strong case against the defendant, a more active defense is
required. In such a case, Rachels states that there are two options available.
The defendant may deny having done the criminal act in question. Or, while
admitting to the act, the defendant may nevertheless argue that he or she should not be
punished for it. Rachels further elaborating on the second case that there are two legally
accepted ways of arguing that a person should not be punished for an act even while
admitting that the act is prohibited by law and that the person did it. First, an excuse
may be offered, such as insanity, coercion, ignorance of fact, unavoidable accident, and
so on. He states that in case of successfully proving any of the grounds then the
defendant may be acquitted. Second a justification may be offered. A plea of
self-defense against a charge of murder is an example of a justification that you were
insane or that the killing was a tragic accident for which you are blameless or that you
had to kill him in self-defense. If none of these defenses can be made out, then you will
be acquitted of the crime even though you admittedly did kill the victim.
Rachels therefore concludes that it is not quite accurate to say that under
American law the burden of proof is always on the prosecution. If the defendant
concedes to having performed the act in question but claims an excuse or justification
for the act, the burden of proof may shift so that the defense is required to show that he
excuse or justification should be accepted (Rachels, 2003).
Rachels while using the above fundamental procedure in the criminal trials in
American courts proposes a legal scenario in which there is legally a successful
possibility of making active voluntary euthanasia a reality without any adverse
repercussions to the physician who performs such an act.
Rachels states that proposal for legalizing active euthanasia is that a plea of
mercy killing be acceptable as a defense against a charge of murder in much the same
way that a plea of self-defense is acceptable as a defense. He further elaborates that
under his proposal, someone charged with murder could also plead mercy killing; and
then if it could be proven that the victim while competent requested death, and that the
victim was suffering from a painful terminal illness, the person pleading mercy killing
would also be acquitted (Rachels, 2003). Rachels while explaining the above
procedure mentions that under the above proposal no one would be "authorized" to
decide when a patient should be killed. He adds that there are no committees to be
established within which people may cast private votes for which they are not really
accountable; people who choose to mercy kill bear full legal responsibility, as
individuals, for their actions (Rachels, 2003).
How the above procedure would be practically applicable to the cases of voluntary
active euthanasia, Rachels explains the practicality of the case as follows:
In practice, this would mean that anyone contemplating mercy killing would
have to be very sure that there are independent witnesses to testify concerning
the patient's condition and desire to die; for otherwise, one might not be able to
make out a defense in a court of law - if it would come to that - and would be
legally liable for murder. However, if this proposal were adopted, it would not
mean that every time active euthanasia was performed a court trail would
follow. In clear cases of self-defense, prosecutors simply do not bring charges,
since it would be a pointless waste of time. Similarly, in clear cases of mercy
killing, where there is no doubt about the patient's hopeless condition or desire
to die, charges would not be brought for the same reason. (Rachels, 2003)
Rachels after proposing the above proposal claims that under the proposal, the
need to write difficult legislation permitting euthanasia is bypassed. He further
explains that by following the above proposal we would rely on the good sense of
judges and juries to separate the cases of justifiable euthanasia from the cases of
unjustifiable murder, just as we already rely on them to separate the cases of
self-defense and insanity and coercion (Rachels, 2003).

CHAPTER THREE
Critique of Rachelss Thought on Euthanasia

3.1. Introduction
The criticism of Rachelss thought on euthanasia is the subject of this chapter.
The arguments developed by Rachels are addressed. The chapter analyzes firstly, the
conceptual framework of Rachels and demonstrates its inadequacy on conceptual and
practical basis ; secondly, it demonstrates the theoretical problems in Rachelss
arguments which attempt to prove the distinction between active and passive
euthanasia is morally absurd , therefore, the criticism leads to invalidity of the validity
of active euthanasia on the basis of the permissibility of so called passive euthanasia,
and thirdly, it criticizes Rachelss arguments for active euthanasia by showing their
weaknesses which affect their soundness. In addition, the researcher also shows the
problems in Rachelss proposal on the legalization of active euthanasia which renders
his proposal problematic and impractical. And, lastly, the researcher debates that there
is only one type of euthanasia which is active euthanasia and which ought to be
rejected, due to unjustifiability of Rachelss arguments, and due to reasons that the
cases of active euthanasia are medically mishandled patients whose death is
unnecessarily prolonged by the use of advanced medical technology. Furthermore, the
researcher demonstrates that passive euthanasia in the sense of letting die is not
euthanasia. Passive euthanasia is an invented name for natural death and it is
misconstrued as passive euthanasia by creating confusion between letting die and
withholding, withdrawing and terminating extraordinary medical treatment. Finally,
the researcher shows that Rachelss active and passive dichotomy is a false dichotomy.
Critique of Rachelss Thought on Euthanasia 46
3.2. Criticism of Rachelss Conceptual Framework
Rachelss conceptual framework includes few distinctions: (1) biological and
biographical life; (2) killing and letting die; and (3) ordinary and extraordinary
medical treatment. On Rachelss view, these distinctions allegedly substantiate his
claim for active euthanasia; however, most of the distinctions make sense only if
passive euthanasia is accepted permissible. Moreover, these distinctions make
premises of Rachelss proposed arguments; therefore their analysis and criticism
directly affects the validity of his given arguments.
The following part of the chapter deals the above distinctions respectively.
The researcher substantiates the claim that Rachelss conceptual framework has
various problems which are reasonably not enough to support the soundness of his
position and that of arguments which mainly draw on such concepts.
3.2.1. Criticism of Biological and Biographical Life
In brief, Rachels makes a distinction between biological and biographical life.
Biological life is merely being a living being; whereas biographical life is the sum of
one's characteristics which are: (1) aspirations, (2) decisions, (3) activities, (4)
projects, and (5) human relationships; and theses characteristics are valuable for a
person and their loss would harm that person. Therefore, Rachels states that only
biographical life is morally relevant (Rachels, 1986b, p. 526, 38). Consequently,
Rachels argues for active euthanasia on the basis of the distinction (Rachels, 1986b, p.
54).
In spite of the simplicity of the above distinction, the following study shows
that the distinction between biological and biographical life does not provide a valid
foundation or criteria for the permissibility of active euthanasia. The distinction is
rather inadequate due to: (1) reductive fallacy oversimplification; (2) slippery slope
and (3) inconsistency with the main arguments of Rachels.
The first reason is that Rachelss distinction of biological and biographical life
leads to reductive fallacy; he oversimplifies the human nature. The main implication
of the above distinction is that a human person is defined in functional terms and such
a definition is indefensible both conceptually and practically. From Rachelss
distinction it appears that the biographical life, according to Rachels, is a set of
capacities an entity with biological life should posses. This analysis and the
distinction of biological and biographical life are actually aimed at having a definition
of a human person in functional terms. As a matter of fact, Rachels in holding such a
view is not alone; in the same manner, ethicist like Mary Ann Warren draws a more
sophisticated demarcation between so-called genetic humanity and moral
humanity, claiming only those in the latter group are persons. Persons, she claims,
must meet one of five criteria: (1) consciousness; (2) reasoning; (3) self-motivated
activity; (4) the capacity to communicate; and (5) the presence of self-concepts
(Warren, 1996). Likewise, Joseph Fletcher adds the capacities: (1) self-control; (2) a
sense of the future and the past; (3) the ability to relate to others; and (4) curiosity
(Fletcher, 1972). As a result, on this view, the definition of a human person relies on
certain properties, capacities, and functions.

The above functional view is basically derived from Rene Descartes or John
Locke. Descartess cogito, ergo sum shows what is to be; he claims that a thing
cannot exist without its essential components but being united with the human body
in the proper sense is no part of the essence of mind (Descartes, 1931, p. 97).
Likewise, Locke defines a person as a thinking intelligent being, that has reason and
reflection, and can consider itself as itself, the same thinking thing in different times
and places by that consciousness, which is inseparable from thinking (Locke, 1894, p.
246). According to Descartes and Locke a human person is someone who is actually
acting at the time in a rational manner. In short, if one is acting rationally one is a
person. On the contrary to the above view, there are philosophers on the opposite side.
Aristotelian and Thomastic position argues that there is no distinction between a
human person and a human being; they are inseparable. According to Aristotle, the
human being is defined as one composite substance - the vegetative, sensitive and
rational powers of the soul together with the human body. The whole soul is
homogenous, and in each part of the body as one whole composite; this means that
the several parts of the soul are indiscoverable from one another (as cited in Irving,
1993, endnote. 38). For Thomas Aquinas the name of person does not belong to the
rational part of the soul, nor to the whole soul alone - but to the entire human
substance. He further explains that human being is a human person, and the later
characteristics, such as rational attributes, autonomous willing or sentience, are only
consequential and secondary or accidental actions which follow upon certain powers ,
not parts, which themselves follow upon the essential nature of the human being itself
( as cited in Irving, 1993, endnotes.42, 43).

The above two opposing trends of thought on divisibility of a human being
has been the center of the philosophy of mind; the discussion in the philosophy of
mind revolves around the distinction between mind and body. This conceptual
divisibility has taken different names and in a derived sense the distinction of human
being and human person belongs to the same category. The survey of this
distinction in the philosophy of mind shows that substance dualism is a discredited
position, and the rest of the positions are either inclusive of or reduced to material or
biological substance. Thus, these theories, in aggregate, lead to the conclusion that the
above mentioned distinctions could be made conceptually but not physically.
The abovementioned conflicting views show that even conceptual
demarcation between a human person and a human being could not be demarcated
precisely; however the practical aspects of such conceptualization are ethically
relevant to the modern developments such as euthanasia and abortion. Therefore, any
derivation on the conceptual distinction of a human entity for justifying the matters of
life and death has practically indefensible consequences. The definition of a human
person in functional terms by ethicists like Rachels, Mary Ann Warren, and Joseph
Fletcher, is not a matter of conceptual hair splitting but of practical nature.
From the functional definition of personhood, it follows that essential
personhood is a degreed property. Therefore, it is undeniable that the first several
years of normal life outside the womb include an increasing expression of human
capacities. Likewise, the last several years of life may include a decreasing expression
of human capacities. Consequently, if the functionalist view is correct, the possession

of personhood could be expressed by a bell curve, in which a human being moves
toward full personhood in her first years of life, reaches full personhood at a given
point, and then gradually loses her personhood until the end of her life. Presumably,
the commensurate rights of persons would increase, stabilize and decrease in the
process. Without appealing to something other than function, it is difficult to resist
this counterintuitive conclusion. Indeed, intellectual honesty has driven many to
embrace this conclusion, and the slope is ever so slippery. In the same manner, Helga
Kuhse and Peter Singer comment on the ontological status of newborns:
. . . . When we kill a newborn, there is no person whose life has begun.
When I think of myself as the person I am now, I realize that I did not
come into existence until sometime after my birth. . . . It is the
beginning of the life of the person, rather than of the physical organism,
that is crucial so far as the right to life is concerned. (as cited in
Mitchell & Rae, 1996, p. 30)
Furthermore, if the functional model is true, then the mentally ill and retarded,
drug and alcohol addicts and patients with Parkinson's and Alzheimer's diseases are
not persons. The threat is that such model has potential of including the various types
of people with disabilities or diseases. Now it must be admitted that these arguments
apply to the newborn baby as much as to the fetus. And philosopher Richard Frey
pushing Singer's logic one step further, suggests that mentally ill human beings are
therefore also not "persons", and therefore they might be used in purely destructive
experimental research in place of the higher animals who are "persons"( as cited in
Irving, 1993, endnote.97).
The oversimplification of a human being in the terms of capacities as
described above becomes more troublesome and slippery if Rachelss distinction is
applied in deciding life and death matters. According to Rachels the importance of a
biographical life is that a person has the capacity to set and achieve goals, plans, and
interests that are important from the point of view of the individual. To better grasp
this, consider Rachelss treatment of the 1973 "Texas burn case" where a man known
as Donald C. was horribly burned but was kept alive for two years in the hospital
against his will, and is still alive today. Rachels believes this man's desire to die was
rational because he had lost his biographical life. Rachels suggests:
Now what could be said in defense of the judgment that this man's desire
to die was rational? I believe focusing on the notion of his life (in the
biographical sense) points us in the right direction. He was, among other
things, a rodeo performer, a pilot, and what used to be called a "ladies'
man." His life was not the life of a scholar or a solitary dreamer. What his
injury had done, from his point of view, was to destroy his ability to lead
the life that made him the distinctive individual that he was. There could
be no more rodeos, no more aeroplanes, no more dancing with the ladies,
and a lot more. Donald's position was that if he could not lead that life, he
didn't want to live. (Rachels, 1986b, p. 54)
As illustrated in the above example, it appears that Rachelss definition of

the biographical life is a very loose definition. The definition does not only justify
mercy killing for suffering terminally ill patients, but also its inclusiveness
justifies killing any one who by the definition seems to fulfill the requirements.
Therefore, euthanasia on such formulation is not only for terminally ill patients as
Rachels argues in his works but for those non terminally ill patients too, who have
lost hope or by some misfortune could not live the life they strive for. The other
aspect of this definition is that if the definition is decisive on life and death of a
person then many other persons besides terminally ill patients will loose right to
life involuntarily. Therefore, Rachelss distinction of biological and biographical
life fails as the distinction entails more than what Rachelss work demands and
accepting such a distinction becomes easy target to slippery slope. Therefore, the
distinction on its own is not sufficient enough to declare a human being
impersonal. As a matter of fact, from the practical point, the Dutch scenario
attests the above inevitable consequences. Herbert Hendin, of the American
Foundation for Suicide Prevention, and two Dutch colleagues, writing in the
Journal of the American Medical Association (June 4, 1997), maintains that
Holland is already sliding down the "slippery slope." In recent decades, they write,
"the Netherlands has moved ... from euthanasia for terminally ill patients to
euthanasia for those who are chronically ill, from euthanasia for physical illness
to euthanasia for psychological distress, and from voluntary euthanasia to non-
voluntary and involuntary euthanasia" (Hendin, 1997, pp. 128-130).
Nevertheless, Rachelss distinction of biological and biographical life
makes sense in the cases when a dying patient is kept alive by the employment of
life sustaining machines, however, in such a case killing actively is not the only
option, in such a case , the extraordinary medical treatment can be withdrawn or
withheld. Therefore, active euthanasia becomes unnecessary. Moreover, further
problem which emerges from the distinction is that the generality of the
distinction leads to abuse of patients on wider scale.
Again, even though the distinction of biological and biographical life is
supposed to be valid on its own, as a result, problems emerge in Rachels's thought,
because the distinction defines a human person in way which is not coherent with
the main arguments of Rachels which are based on patients consent and
autonomy. The distinction, consequently, leads to permissibility, not only of
voluntary active euthanasia, but also of non-voluntary and involuntary. Although,
Rachels advocates only for permissibility of voluntary active euthanasia in his
main arguments, but his distinction entails the consequences which hardly seem to
escape being the easy target of slippery slope. If the distinction is sufficient, then
any need of patient consent becomes irrelevant. Therefore, the distinction leads to
inconsistency and incoherence in Rachels's thought, and the distinction becomes
irrelevant to Rachelss main arguments for active euthanasia, which are best
interest and golden rule argument and autonomy argument. And both these
arguments are based on patient consent and autonomy.
3.2.2. Criticism of Killing and Letting Die
Killing and letting die distinction in other words could be formulated as
omission and commission. Rachels argues that there is morally no distinction between
killing someone and letting someone die. The implication of the distinction is related
to the active and passive dichotomy. Rachels by applying above concept attempts to
show that the active and passive dichotomy is a distinction without difference. He
calls it the equivalence thesis, and the main argument for it is called the bare
difference argument: Rachels hypothesizes two cases that are supposed to be exactly
alike except that one involves killing and the other involves letting die. Rachels uses
the distinction in many arguments to force his viewpoint. The distinction is very vivid
in his arguments such as mercy argument, bare difference argument and etc.
The researchers counter position to Rachels is that the distinction between
killing and letting die is: (1) irrelevant, (2) extraneous to the medical profession, and
methodologically degressive.
3.2.2.1. Killing and Letting Die: An Irrelevant Distinction
The killing and letting die discussion is both relevant and irrelevant to the
issue of euthanasia. The relevance could be made when a doctor intentionally
withdraws or withholds the treatment to kill a curable patient; and if such treatment is
continued the patient will live healthy. Thus, in this case there is no difference
between killing and letting die. The distinction is irrelevant to euthanasia because it is
not the case that doctors let the patient die with the intention of killing. The
researchers main claim is that though killing and letting die may be of importance in
various moral issues, however the distinction is itself irrelevant to the issue of
euthanasia. The distinction is unnecessarily brought into the debate on euthanasia to
support killing on the basis of letting die, whereas in fact letting a patient die
intentionally is not supported by doctors or practically found happening. The
distinction misrepresents the act of withholding, withdrawing and terminating
extraordinary medical treatment, and equates it with letting die. From the very
commonsense point of view, one can save a dying person if the person is in the range
of recovery and when such a person is out of such a range , it is not possible to save
such a person and death of such a person could not be termed as letting die . The
following very simple hypothetical example shows the issue clearly:
Jason was walking on a bridge which is over a deadly river and suddenly he
heard a bomb explosion. He found that the people were running and falling. The walls
of the bridge were destroyed. He found on his right a person, Adam, who was
hanging there grabbing the destroyed wall of the bridge and was about to fall into the
river. On Jasons left was Peter who had just fallen from the bridge and was crying,
falling toward the river and was out of Jasons reach. Jason hopelessly looking at
falling Peter gave his hand to Adam and rescued him.
In the above example the following two cases could be made:
1. Jason saved Adam, because Adam was about to fall and die, however it was
possible for Jason to rescue him. Should Jason be praised for his action or
should he be blamed for not letting Adam die?
2. Jason saw that Peter had already gone out of his reach and was falling to the
river. Should Jason be blamed for letting Peter die?
The response to (2) is clear that Jason did not let Peter die. It was not possible
for him to save him because Peter had gone out of his reach. The same happens in the
hospitals where a person with a curable disease is saved and those who are incurable
with deadly disease are left on their own with some help which could minimize their
suffering. Rachels treats the issue as letting die. Whereas, the fact is that doctor did
not let the patient die; he simply could not do anything about it. Nevertheless, if a
doctor withholds the treatment from a patient who suffers a curable disease and dies
due to doctors negligence or refusal of treatment, in such a case, it could be claimed
that letting die takes place. Rachels confuses both these cases and tries to make his
point by claiming that the doctor let the patient die in the first case.
The AMAs statement actually holds that it is not allowed to kill a patient and
if the medical treatment seems hopeless and useless, in such a case the patient has
choice to refuse the extraordinary treatment. As the treatment apparently is not going
to show any improvement in the health condition of the patient, the doctor and the
patient, both have reason to agree on termination of medical treatment. The future of
the patient remains hidden with possibilities in the future, and the possibility of
patients recovery from the disease could not be just anticipated as impossible, the
evidence to contrary shows that there are such patients who have recovered after
certain time.
Basically AMAs statement involves two choices: (1) that it is impermissible
for the doctor or anyone else to terminate intentionally the life of a patient, but (2)
that it is permissible in some cases to cease the employment of "extraordinary means"
of preserving life, even though the death of the patient is a foreseeable consequence
(Sullivan, 1994a, p. 132). The first choice could be classified as active euthanasia, it
includes actively killing a patient and AMAs statement prohibits it. The (2) choice
deserves a clarity. Rachels tries to classify the second option as passive euthanasia
and his definition of passive euthanasia literally means letting die. However, as
shown in the above example the (2) is not passive euthanasia in the sense Rachels
treats it. Therefore, the application of killing and letting distinction to euthanasia is
irrelevant.
3.2.2.2. Killing and Letting Die Distinction and Health Care Professions
The distinction between killing and letting on the wording of Rachels is that in
passive euthanasia a patient is killed by letting him die and in active euthanasia a
patient is killed and both these acts are due to the terminal illness of the patient.
Therefore, killing and letting die are the same and if passive euthanasia is allowed,
active should be permitted too.
Rachelss understanding of the distinction of killing and letting die is actually
inspired by a certain legal and moral understanding of the omission and commission
distinction. The legal position on the distinction varies in different countries and legal
systems. Ernest S. Weinreb (1980) states that in Anglo-American common law unlike
many other legal systems, no general duty requires a passerby to render a stranger
affirmative assistance. Despite the legal tradition, many in America and England
passionately argued that anyone who failed to render assistance should be prosecuted.
Some American states, including Vermont, Minnesota, and Rhode Island, have
adopted statutes requiring strangers to provide affirmative assistance to persons in
distress when they can do so without harm to themselves (as cited in Gorsuch, 2000,
footnote. 239); however, the legal and moral standing on the issue in special
professions is different. The professional situation where a special relationship exists,
and the patient-physician setting is a paradigmatic example, omissions of ordinary
care are as punishable as affirmative misdeeds. Indeed, a physician's omission of
readily available treatment is clearly a professional malpractice.
In light of the above, the distinction of killing and letting die is very
extraneous to the medical profession. If the distinction is allowed to find its
acceptance into the discipline, it would lead the profession to the wrong side; literally
the profession will become not only life saving but also life taking. As a result, life
care professions will be endangered. The application of the distinction becomes
irrelevant to the professions meant for life caring such as life-guards, fire-fighting,
health care, child care and early child-hood centers such as nurseries, and baby care
centers etc. Here particularly, health care needs a special discussion. Health care or
medicine develops from the objective to save lives and not to take lives. Killing or
letting die a patient changes the definition of the profession itself. The severity of the
issue has given a serious concern to doctors in the field of medicine as follows:
This issue touches medicine at its very moral center; if this moral center
collapses, if physicians become killers or are even merely licensed to kill,
the professionand, therewith, each physicianwill never again be
worthy of trust and respect as healer and comforter and protector of life in
all its frailty. For if medicine's power over life may be used equally to heal
or to kill, the doctor is no more a moral professional but rather a morally

neutered technician. (Gaylin, Kass, Pellegrino, & Siegler, 1989, p. 26)
Besides the irrelevance of the distinction to the nature of medical profession,
the introduction of the distinction into the profession violates many other foundations
and historical professional grounding of the profession; as first of all it grows the
mistrust and suspicion between the patient and the doctor and secondly this kind of
intrusion is not without other repercussions which freely lead to slippery slope and, in
consequence, elderly people would be eliminated not just because of the reason of
health but of economy. Moreover, the distinction will have adverse psychological
impact on patients; the patient can no longer look at his physician as his advocate for
the extension of lifebecause when in the mind of that physician that patient's life is
waning, the sick person has no guarantee that the physician will approach him in the
role of life preserver; he may be coming as executioner (Koop, 1976/ 1989a, pp. 82-
83).
The relationship between a doctor and patient is professionally that a patient
submits himself to a doctor and entrusts him his life. In such a relationship the doctor
takes the patient through many stages with the hope to save his life. The following
statement clearly depicts the doctors role in handling the patients at various stages of
the health conditions.
I am in the life-saving business and that comes first, but I recognize also that
I am in the business of alleviating suffering. I never take a deliberate action
with the motive of terminating a patient's life. It is possible that a patient's
life might be shortened by some therapeutic measure I employ with the intent
of relieving suffering. In some circumstances where I believe that I have
sufficient experience and expertise with the life history of a disease process
and my patient's response to that disease as well as to his therapy, I might
withhold treatment that could be considered extraordinary or heroic in the
given circumstance in reference to the quality of life that might be salvaged
for a short period of time. (Koop, 1976/ 1989a, p. 83)
Gay-Williams (1979/1989) while criticizing permissibility of euthanasia on
practical grounds, states that doctors and nurses are, for the most part, totally
committed to saving lives. Their failure in saving a life is like a personal failure and
an insult to their skills and knowledge. He refers to the possibility that euthanasia as a
practice might well alter this. Moreover, it could have a corrupting influence so that
in any case that is severe doctors and nurses might not try hard enough to save the
patient. They might decide that the patient would simply be better off dead and take
the steps necessary to make that come about. He concludes that this attitude could
then carry over to their dealings with patients less seriously ill. The result would be an
overall decline in the quality of medical care (pp. 100-101). Gay-Williams said
concern leads to other concern which is methodologically of crucial importance to the
medical profession. It is a well known fact that the diseases which are easily curable
in our time are the same diseases which were considered fatal at some point of the
history. It is due to hard efforts of medical scientists that their cure became possible.
Against this history of achievements in the medical science, if Rachelss distinction
of killing and letting die is positively considered in the practice of medicine, it will
lead to methodological problems into the discipline. There is possibility that those
patients who are suffering from deadly diseases will be killed and the effort needed to
help such cases will not be spent. So the introduction of the distinction into medical
practice creates two main problems one is that it changes the definition of the
profession and such definition creates other problems such as mistrust between the
patient and the doctor, secondly it removes the skeptic nature of scientific
methodology which is progressive and the distinction aims at terminating every odds
without making any effort to find any solutions.
3.2.3. Criticism of Ordinary and Extraordinary Means of Treatment
Rachels while finding flaws in the American Medical Associations policy
statement claims that the statement states that life sustaining treatment may
sometimes be stopped if the means of treatment are "extraordinary", Rachels adds, the
implication is that "ordinary" means of treatment may not be withheld. To above
position, Rachels states that, however, upon reflection it is clear that it is sometimes
permissible to omit even very ordinary sorts of treatments (Rachels, 1981/ 1994b,
p.143).
Rachels debates the definitions of ordinary and extraordinary forwarded by
Paul Ramsey and supported by Thomas Sullivan. Rachels criticizes the definition is
useless. He states that two problems regarding the distinction and shows that the
distinction is senseless. He firstly criticizes the way the word "excessive" functions in
these definitions. Secondly, Rachels turns to the use of the word "benefit" in the
definitions. Rachels concludes that if the distinction is applied in a straightforward,
commonsense way, the traditional doctrine is false, for it is clear that it is sometimes
permissible to omit ordinary treatments. On the other hand, if we define the terms as
suggested by Ramsey and Sullivan, the distinction is useless in practical decision
making (Rachels, 1981/ 1994b, p. 145).
In response to Rachels, the researcher argues that Rachelss claim against
AMA statement is not valid. There are two reasons to support such a claim: (1)
AMAs statement does not make any distinction between ordinary and extraordinary
medical care and (2) the distinction of ordinary and extraordinary is useful in
practical decision making.
The first reason as stated above is that AMAs statement does not make a
distinction between ordinary and extraordinary medical treatment. The statement is
rather carefully worded; it mentions only the cessation of the employment of
extraordinary means to prolong the life. The statement does not mention what is
ordinary and what is extraordinary. The fact is that there is always something
extraordinary about everything. And, what Rachels thinks is ordinary, may in fact be
extraordinary, and vice versa. The drafting committee of the AMAs statement has
shown sharpness and wisdom in avoiding any demarcation between ordinary and
extraordinary medical treatment. Professionally, what could be classified as ordinary
and extraordinary in the medical treatment is by no means a laypersons game. Even
the most ordinary aid such as food and water could become extraordinary in
circumstances when a person is feed by tubes in a vegetative state. Therefore, the
demarcation of ordinary and extraordinary should be left to the experts of the field as
the researcher considers it in the second reason.

The second reason is that the distinction between ordinary and extraordinary
medical treatment is valid and useful. The fact is that the definition of ordinary and
extraordinary is evolutionary in its content. Technologically, medicine has advanced
so quickly that older, unwritten understandings of "ordinary" and "extraordinary" care
no longer seem applicable. What might have been considered "extraordinary" care a
few years ago is now so commonplace as to be called "ordinary" - respirators,
pacemakers, kidney dialysis machines, etc. The following example is very suitable in
discerning the nature and meaning of ordinary and extraordinary medical treatment.
If one had acute appendicitis and postoperatively developed a situation
where his kidneys did not function, to put him on a dialysis machine (an
artificial kidney) which could handle his urinary function temporarily
would be an extraordinary act and might at times be considered to be
"extraordinary" care. However, in a vigorous, alert, productive individual
with a normal life expectancy of several decades ahead of him, it should not
be considered "extraordinary" care. On the other hand, if in a ninety-year-
old individual the same kidney shutdown took place and was the result of a
disease process that inevitably would take this patient's life, the institution
of dialysis would be an "extraordinary procedure" and would definitely be
thought of, by any medically competent individual, as providing
"extraordinary" care. (Koop, 1976/ 1989a, pp. 72-73)
The above example shows that the difference between ordinary and
extraordinary treatment is a matter of physicians experience , it would most of the

time depend on many factors such as the condition of the patient, and to what level a
patient would be able or viable to bear the expenses of in case any expensive aid or
treatment is required. Rachelss view that there is no demarcation between ordinary
and extraordinary treatment is therefore an uneducated guess. The distinction between
ordinary and extraordinary treatment depends on the wisdom of a physician what his
prudence would lead to. It is worthwhile to quote Max J. Charlesworth as follows:
But while there is obviously something in this distinction [ordinary and
extraordinary] it is, as we have seen, a relative and variable one. In fact, it is
rather like the legal criterion of 'the reasonable man'. In certain cases we ask
ourselves, 'What would the reasonable man have done? ' or 'How would the
reasonable man have acted in this situation?' We are all aware that this is a
very rough and ready criterion since what the 'reasonable man' would have
done in Victorian times in the nineteenth century is clearly very different
from what the 'reasonable man' might do in our present enlightened and
liberated times. Again, what the Anglo-Saxon 'reasonable man' might do
will be very different from what the Turkish or Greek 'reasonable man'
might do. Nevertheless the criterion works in a rough and ready way at the
practical level. (Charlesworth, 1989, pp. 65-66)
The second objection which Rachels poses to ordinary and extraordinary
treatment is about the use of the word "benefit" in the definitions. It is said that
ordinary treatments offer a reasonable hope of benefit for the patient; and that
treatments are extraordinary if they will not benefit the patient. Rachels notes that
how do we tell if a treatment will benefit the patient? Again, the point is that in order
to decide whether life-sustaining treatment is a benefit we must first decide whether it
would be a good thing for the life in question to be prolonged(Rachels, 1981/ 1994b,
p. 145). The objection of Rachels could be responded by stating that first of all the
distinction between ordinary and extraordinary firstly depends on the prudence of the
practitioner as stated above and secondly it appeals to the severity of the condition a
patient goes through. The benefit of the care to the patients health condition is what
is a real matter a doctor should be concerned about not what Rachels suggests. Should
the life in question to be prolonged is something very judgmental on life and death
and a doctor is not supposed to be judging that. It must always be clear that the
doctor's role is not to assess the value or worth of the patient but that of the treatment'
(British Medical Association, 1999/ 2007, p.8). The real concern a doctor should have
is that will the available care to patient make an ordinary or extraordinary treatment.
Therefore, Rachelss claim is normatively unjustifiable because the benefit of the care
to the patients health condition is what is a real matter a doctor should be concerned
about; deciding the life and death of the patient puts the physician in an unwarranted
prerogative role which is problematic due to legal complexities, rights, duties, and
autonomy. Such a judgmental role is also prone to abuse and corruption. Therefore,
the doctors role is not to assess the value or worth of the patient but that of the
treatment.
3.3. Criticism of Rachelss Arguments against Traditional Doctrine on
Euthanasia (TDE)
Rachels argues against the traditional doctrine on euthanasia (TDE) or
conventional doctrine on euthanasia (CDE) which is also called as conventional view
or standard view which makes a distinction between active and passive euthanasia.
This view, on Rachelss understanding, is upheld by the American Medical
Association. According to Rachels the conventional view, passive euthanasia is
sometimes permitted whereas active euthanasia is never permitted. It is necessary to
note here that AMAs statement which is the actual target of Rachelss criticism does
not make such a distinction. The statement disallows intentional killing of terminal
patients and permits the termination of extraordinary medical care, in doing so the
statement allows the cessation of medical treatment in extraordinary cases.
In arguing against CDE Rachels gives four arguments which on his
formulation render the distinction between active and passive euthanasia morally
absurd. Therefore, Rachels tries to prove that whereas passive euthanasia is allowed
active euthanasia should be permitted too. The arguments are explained in the second
chapter of this research. In the following part of the chapter the researcher, after
highlighting the main points of Rachelss arguments, criticizes the arguments
respectively.
3.3.1. Criticism of that often Active Euthanasia Seems More Humane than
Passive
Rachels claims that often active euthanasia seems more humane than passive
and therefore active euthanasia should not be only permitted but preferred too.
Rachels reinforces his position in mercy argument. He illustrates the claim by
examples of terminally ill patients to show that allowing the patient to die is much
more painful and inhumane than active euthanasia (Rachels, 1975/ 1994a, p.113).
The logical form of the argument according to Don Berkich is as follows:
1. If CDE is true then passive euthanasia never produces more suffering than
active euthanasia.
2. It is not the case that passive euthanasia never produces more suffering
than active euthanasia.
Therefore
3. CDE is not true. (1& 2). ( Berkich , 2003 )
Rachels above argument mainly faces two responses which render his
argument invalid. The first response is that Rachels argues against CDE on the basis
not included in the AMAs statement. Rachelss argument against AMAs position is
irrelevant. Rachelss arguments against CDE are actually supposed to be strictly
against the text of the AMA statement, whereas the above argument actually does
not address the statement. The AMAs statement does not make difference because of
pain or suffering. Therefore, Rachelss argument does not render the statement false
or invalid. According the AMAs statement, CDE is not based on suffering and no
consideration is included on methods which produce less or more suffering. The
validity test of the argument turns the argument invalid if the case is strictly
considered against the AMAs statement. Because, AMAs statement makes the
difference between killing and termination of extraordinary medical treatment. The
suffering as such is not the part of the statement. Therefore, the argument doest not
give any problem to AMAs position.
The second response could be made if Rachelss argument is taken against
CDE from the point of suffering as a separate argument with the content not
considered in AMAs statement; that killing a terminally ill patient is better than
leaving the patient suffer in pain. The argument from its simplicity, make a
convincing point. However, the following arguments can be made against such an
argument which render Rachelss argument unimportant, irrelevant, and inadequate.
The first point is that, though, a person is thought to be dying after a few days
when such a patient is terminated from medical treatment as a potential subject to
death, still the fact of dying is in the future. Will that patient die or live another few
healthy years is not known as a matter of fact. There are cases in which the
terminated person lived longer or healthier after being terminated from the treatment.
To show how difficult predictions might be, Medical World News on May 5, 1974,
reported a case of a woman with myasthenia gravis who lived "artificially" for 652
days in intensive care and then made a remarkable recovery. Said a hospital
representative at the Harbor General Hospital in Torrance, California, "She made us

recognize that there was no such thing as inordinate effort. She had such a tenacity for
life we felt that everything we did, no matter how extraordinary, was appropriate to
the situation (Koop, 1976/ 1989a, p.73). The case from the practical point goes
against the active euthanasia, because recovery is a probability, therefore it is better to
terminate the medical aid than actively kill a person. It is a well known fact that
people have been known to recover from comas after considerable periods, and some
terminally ill patients make miraculous recoveries. Allowing euthanasia would risk
killing people who could otherwise have had years more life. With euthanasia the
price of a mistake is too high. Philosophically, appeal to the future is itself a fallacy,
arguing that evidence will someday be discovered which will, then, support your
point. Now this appeal to the future as a fallacy applies to argument for active
euthanasia instead of terminating extraordinary medical care. In case of terminating
extraordinary medical treatment, the doctors withhold or withdraw the medical
treatment on the conviction that the treatment is useless and the patient will die,
whereas within the same conditions of conviction, in active euthanasia, the doctors
kill the patient. It is the second case in which doctors, if allowed, are about to commit
the fallacy as they take the future as a fact and granted.
The second point is that modern advanced medical technology has most
developed treatment to control the pain or suffering of a patient. Therefore, the
argument which states that a suffering person could be killed has no basis except that
the medical care is not ready to support those ant-pain killing treatment.
The pain and suffering should they be the basis for deciding the permissibility
of active euthanasia, the case is contrary to what Rachels states. If the need of active
euthanasia is due to suffering, but, on the other hand, suffering could be controlled by
medication without actively killing a patient, therefore active euthanasia seems
undesirable. With the highly effective painkillers now available there is never any
need even for the terminally ill to suffer great pain. Use of painkillers, not euthanasia,
is the answer to painful terminal illness. [I]n up to 90 percent of [cancer] patients,
the pain can be controlled by relatively simple means. Nevertheless, under treatment
of cancer pain is common because of clinicians' inadequate knowledge of effective
assessment and management practices, negative attitudes of patients and clinicians
toward the use of drugs for the relief of pain, and a variety of problems related to
reimbursement for effective pain management (Jacox, Carr, & Payne, 1994, p.651-
655).
The other connected issue is that if suffering is the basis for permissibility of
active euthanasia then only terminally ill patients are not the only subjects of the
active euthanasia, there are many patients with diseases and suffering who are not
terminally ill. Kelley & Clifford (1997) reported that Edwin S. Schneidman, founder
of the American Association of Suicidology, maintains that dying is not painful; it is
the illness that causes the pain. However, an individual does not have to have a
terminal illness to have intractable pain, to which many people with conditions such
as arthritis and fibromyalgia will attest (as cited in Manetta & Wells, 2001).
The other important notion which is connected with suffering is the
conception of suffering itself. The suffering can be physical and it can be mental or
psychological. The euthanasia supporters may claim the end to physical suffering but
what about psychological suffering. If suffering becomes the basis for the
permissibility of active euthanasia, then many patients who are not terminally ill but
psychologically suffering or non-terminally ill patients , will be subjects of euthanasia
as well. Therefore, suffering as itself is an inadequate reason for permissibility of
active euthanasia. The other reason is that suffering is actually about the attitude. The
argument from suffering reaches beyond medicine's responsibility and competence; it
extends into metaphysical questions about the nature of human happiness and of what
constitutes a meaningful life. To enlist a physician to achieve release from a
meaningless life of suffering presumes that the physician is competent to judge what
kinds of life is worth of living. The roots of suffering are more than physical. The
degree to which people suffer and whether they find life empty or meaningful depend
more on their attitude than on their physical condition (Gula, 1999a, pp.501-5).
From the practical point of view, suffering is irrelevant to the issue of
euthanasia due to advances in palliative care. In many cases of terminal cancer the
choice is no longer between dying in agony and deliberately ending one's life since
appropriate palliative care enables such patients to live out their lives in relative ease
and peace. However, while it may be true that in many cases one may die in such a
way as to keep one's self-respect without taking measures to end one's life, there are
surely many situations where a person might, for very good reasons, no longer wish
to prolong his or her life. These cases are cited in Rachelss works also. He illustrates
his arguments by such examples. However, the reason which renders such a position
invalid is that the cases are of patients who were kept alive by extraordinary means;
their death was prolonged due to inappropriate use of advanced medical technology.
One of the famous examples of such cases is of Karen Ann Quinlan (March 29,
1954 June 11, 1985). When she was 21, Quinlan became unconscious after coming
home from a party, and lapsed into a persistent vegetative state. After she was kept
alive on a ventilator for several months without improvement, her parents requested
the hospital discontinue active care and allow her to die. Karen Ann Quinlan's
parents, for example, believed that their daughter would not have wanted to live in a
comatose, 'human vegetable', state for ten years. But, as we know, they were unable
to get her physicians to discontinue her life-sustaining treatment (Charlesworth,
1989, pp. 75-77). Karens case is one of the most illustrated cases in the history of
euthanasia. The analysis of her case clearly shows that she was kept alive in
vegetative state for long time , had her life sustaining machines disconnected she
could have died earlier with out suffering herself and her parents. The point is that if a
person could not be cured by ordinary medical treatment and providing extraordinary
treatment to such a patient when death is foreseen would only create suffering.
Unfortunately, Rachels has nothing to say about it in his works. He has not made any
contribution in showing that the root cause of pitiful cases is actually mishandling of
patients by advanced medical technology.
However, responding to above counter reasoning, Rachels can argue and he
has actually argued that there are still patients, their death is foreseen and instead of
killing them they are left to die and their dying process takes days and weeks in
suffering. He therefore argues that such patients could have been better off by active
euthanasia by putting end to their suffering. The researcher argues against it from two
reasons. The first as elaborated earlier is that pain killers and palliative care has made
suffering irrelevant. The second reason is that those patients who are terminally ill
and their life may be miserable due to the pain which is caused by illness. For such
patients double doctrine effect opens the way and avoids any need of active
euthanasia. Simply, those patients will go through their dying process and their pain
will be controlled by medicine even though such medication may shorten their lives
as a side effect, so the shortening life will be treated as a side effect and not as the
intended consequence. This last solution which prescribes pain medication to painful
terminally ill patients comes with the famous principle called as Doctrine of Double
Effect (DDE).
There are many names for Doctrine of Double Effect (DDE) such as Principle
of Double Effect (PDE), Rule of Double Effect (RDE), Double-Effect Reasoning
(DER), and simply Double Effect. The mention of DDE is of paramount importance
because of its use in practical medicine and its existence as a backbone for many
arguments which propose pain medication to alleviate the suffering of terminally ill
patients. Thomas Aquinas is credited with introducing the principle of double effect
in his discussion of the permissibility of self-defense in the Summa Theologica (II-II,
Qu. 64, and Art.7). According to him, nothing hinders one act from having two
effects, only one of which is intended, while the other is beside the intention (as
cited in McIntyre, 2004). The classical formulation of the principle requires
fulfillment of four conditions if the action in question is permissible: (1) that the
action contemplated be in itself either morally good or morally indifferent; (2) that
the bad result not be directly intended; (3) that the good result not be a direct causal
result of the bad result; and (4) that the good result be "proportionate to" the bad
result. Where all these conditions are met, the action under consideration is morally
permissible despite the bad result (Solomon, n.d. Formulation of the Principle).
Thought the doctrine has many applications; in particular, its application in
treating terminally ill is widely accepted and traditionally practiced. The principle is
used to justify the case where a doctor gives drugs to a patient to relieve distressing
symptoms even though he knows doing this may shorten the patient's life. This is
because the doctor is not aiming directly at killing the patient - the bad result of the
patient's death is a side-effect of the good result of reducing the patient's pain. Many
doctors use this doctrine to justify the use of high doses of drugs such as morphine for
the purpose of relieving suffering in terminally-ill patients even though they know the
drugs are likely to cause the patient to die sooner. The double effect doctrine, as
applied in medicine, is based on two basic presuppositions: the doctor's motivation is
to alleviate suffering; and the treatment must be proportional to the illness. The
doctrine applies if 1) the desired outcome is judged to be good e.g., relief of suffering;
2) the bad outcome e.g., death of patient is not intended; 3) the good outcome is not
achieved by means of the bad, and 4) the good outcome outweighs the bad (Cohen-
Almagor, 2000, pp. 267-278). Theses conditions of the principle are well elaborated
on practical grounds by Wanzer et al. (1989/1990); they suggest that in the patient
whose dying process is irreversible, the balance between minimizing pain and
suffering and potentially hastening death should be struck clearly in favor of pain
relief. They recommend that pain medication should be given in whatever dose and
by whatever route is necessary for relief. They further suggest that in extreme cases it
is morally correct to increase the dose, even though the medication may contribute to
the depression of respiration or blood pressure, the dulling of consciousness, or even
death, provided the primary goal of the physician is to relieve suffering. They suggest
that however the proper dose of pain medication is the dose that is sufficient to
relieve pain and suffering, even to the point of unconsciousness (p. 287).
It is therefore an accepted practice to use doctrine of double effect in such cases
which contain suffering. Even in cases where death is imminent and pain cannot be
minimized or eliminated through normally accepted dosages of medication, active
euthanasia is not the only option. A doctor can give the necessary pain medication if
the intent is solely to alleviate pain and not to kill, even if it can be foreseen that such
an action will hasten death. In this case death is a foreseen, tolerated, but an
unintended effect.
3.3.2. Criticism of the Conventional View Makes Life-And-Death Decisions
on Irrelevant Grounds
Rachels claims that the conventional view makes life-and-death decisions on
irrelevant grounds therefore the conventional view, CDE, is not true. In support of
the claim he refers to the case of babies with Down syndrome. He emphasizes the
cruelty involved in permitting the child to suffer when there is a lethal injection
available that can put him out of his misery. Rachels draws the attention towards that
if the lives of these infants are worth living, then their lives should be preserved.
Allowing to die and actively killing would be equally wrong (Rachels, 1975/
1994a, p.115). Rachels's point is that hence the babies are being left to die; it would
be for better to kill such babies and therefore terminate their suffering. The logical
form of the argument according to Don Berkich is as follows:
1. If acting in accordance with CDE leads to decisions about passive
euthanasia being made on irrelevant grounds, then CDE is false.
2. Acting in accordance with CDE leads to decisions about passive
euthanasia being made on irrelevant grounds.
Therefore
3. CDE is false. (1&2). ( Berkich , 2003 )
What exactly are the irrelevant grounds which Rachels is trying to show? The
grounds which seem irrelevant to Rachels are killing and letting die on the basis of
suffering. To him relevant ground ought to be suffering of the patient which should
be considered in deciding the killing of a patient; that the suffering is what should
allow a doctor to eliminate a human being actively and what minimizes that suffering
should be the relevant ground. The researcher thinks that the case is somehow
different. The relevant grounds in CDE are the ordinary and extraordinary medical
care; there is no mention of suffering at all. The CDE makes case clear that when
doctors are hopeless about the recovery of a patient; then such doctors can
discontinue the treatment. Had the CDE being based on minimizing suffering,
Rachels argument would have won the case from the utilitarian point of view. Simply,
it could be argued that the premise 2 in the argument is false as the relevant ground
for passive euthanasia in CDE is relevant and that is confirming that the employed
health care is useless and most expectedly the patient will die as a natural course. The
concept of suffering in the whole debate seems an interesting invention by Rachels.
His whole thought is based on the same grounds. In every argument he would be
appealing to suffering and showing that suffering could be minimized by active
euthanasia alone.
Allowing to die and actively killing, are the irrelevant grounds which Rachels
thinks that CDE is based on. That allowing to die should be permitted whereas
actively killing should be opposed. As said in the previous argument if a patient is
dying and the process is painful, such suffering can be controlled by the application
of doctrine of double effect. There is no such a need to recourse to active euthanasia.
Therefore, the suffering is not the relevant ground and its irrelevance is shown
in the previous arguments. The relevant grounds are killing and terminating the
extraordinary care. These are relevant in CDE and on this relevance the distinction
between active euthanasia and terminating extraordinary medical care is based.
3.3.3. Criticism of that there is no Moral Difference between Doings and
Refraining
Rachels claims that there is no moral difference between doings and
refraining, therefore wherever refraining is allowed doing should be permitted too.
From the claim, Rachels attempts to prove that wherever passive euthanasia is
allowed active should be allowed too. And, therefore according to Rachels CDE is
false. The logical form of the argument according to Don Berkich is as follows:
1. If killing is morally worse than letting die, then for any two cases C1 and
C2, where C1 and C2 are exactly alike in all respects except that in C1 there
is a killing while in C2 there is a letting die, C1 is morally worse than C2.
2. It is not the case that for any two cases C1 and C2, where C1 and C2 are
exactly alike in all respects except that in C1 there is a killing while in C2
there is a letting die, C1 is morally worse than C2.
Therefore
3. It is not the case that killing is morally worse (1&2)
4. If CDE is true then killing is morally worse than letting die.
Therefore
5. CDE is not true. (3& 4). ( Berkich , 2003 )
In other words, the argument argues that CDE is false by showing that passive
euthanasia is morally no better than active euthanasia or, equivalently, that active
euthanasia is morally no worse than passive euthanasia.
The researchers position is that Rachelss argument is invalid due to four
reasons: (1) irrelevance to AMAs statement; (2) differences between the cases
because of intentionality, causality, and agency; (3) straw man fallacy, (4) and weak
analogy.
The first reason is that the argument is irrelevant to AMAs statement which
does not make any distinction between killing and letting die. The AMAs statement
prohibits the intentional killing and allows the termination of extraordinary medical
treatment. Rachelss argument against the statement is irrelevant because the
statement is not about letting die as elaborated in the conceptual framework of this
chapter.
The second reason is that even if Rachels thinks that withholding
extraordinary treatment is letting die, nevertheless, his argument still fails because in
active euthanasia killing is intended whereas death in passive euthanasia happens
naturally without any intention. The crucial differences between active and passive
euthanasia which make them different are: intentionality, causality, and agency and
these three concepts make a moral difference. Therefore, the premise (1) in the above
argument is invalid. C1 and C2 are not alike; therefore they are not alike morally. It
should be noted here that Rachels is making argument against AMAs statement.
The first argument in favor of above claim is that the intention in both cases is
different therefore the cases are different morally. The difference of intention is well
understood by Rachels; that is why he has disregarded such difference. Moreover,
Rachels is a utilitarian consequantilist, therefore intentions are not considered by him,
and only consequences are relevant to his ethical theory. Rachels suggests that bad
intentions and good intentions are relevant to bad and good characters and they have
no connection with moral actions as such. However, Rachelss disregard of intentions
is not sufficient to remove the importance of intentions from the subject of delivering
any position on any ethical action. The researcher thinks that relevance of intentions
is of importance the morality of actions; furthermore, the researcher suggests the
view that killing and letting die are not just morally different due to intentions alone,
but due to other factors which are morally relevant such as causation and agency.
Rachelss immediate respondent, Thomas Sullivan, pointed out the problem of
intentionality in Rachelss thought and he suggested that Rachels makes the
distinction between the act of killing and the act of letting die be "a distinction that
puts a moral premium on overt behavior moving or not moving one's parts
while totally ignoring the intentions of the agent" (Sullivan, 1977/ 1994a, p. 135). The
fact is that an intentional action or omission is different in character, both morally and
legally, from an unintended consequence. Our intentional actions say something
about us and our character that no unintended side-effect possibly can. Unlike
unintended consequences, our intentional conduct is always within our control. An
intentional act is one of choice. An intended act "remains, persists, ... [and] is
synthesized into one's will, one's practical orientation and stance in the world (Finnis ,
1990). As Charles Fried has put the point:
[I]t is natural that the most stringent moral judgments should relate to
intentional acts.... Morality is about the good and the right way of our
being in the world as human beings. And the way we relate to the world as
human beings is as we pursue our purposes in the world, i.e., as we act
intentionally.... This primacy of intention explains why in law and morals a
sharp line is drawn between the result, which is intended [,] ... and the certain
concomitant, which [is not] intended.... To see a paradox in this distinction
assumes that because the result in the world is the same in the two cases the
judgment in them must be too. In short, it ignores the element of purpose.
(Fried ,1976)
To return to practical nature of euthanasia, the main difference between active
and passive euthanasia is because the intention in both cases is different. In passive
euthanasia, the patients and doctors who resort to withdrawing or terminating medical
care do so not for the reasons of intending the death of the patient. Moreover, the
Patients who decline the extraordinary medical care do so for many reasons that in no
way implicate an intention to die. They may wish to avoid further pain associated
with the invasive treatments and tubes and the poking and prodding of modern
medical care. They may wish to avoid the sense of indignity that dependence on
medical machinery sometimes can bring. They may wish simply to go home from the
hospital, to be with loved ones, and to restore their privacy. None of these decisions--
or any of the other countless reasons for refusing care expressed every day by persons
confronting an inevitable death--involves intent to die even when death is foreseen.
Likewise, those persons who assist patients in declining unwanted treatment need not
necessarily intend death as either a means or as an end. They may intend only to
discontinue treatment to permit the patient to go home, to live without intrusive
assistance, to avoid further pain associated with treatment. They may foresee death as
a result of their actions without ever purposefully seeking it out. As the AMA (1992)
has put the point, the "withdrawing or withholding of life-sustaining treatment is not
inherently contrary to the principles of beneficence and non malfeasance," while
assisted suicide is "contrary to the prohibition against [intentionally] using the tools
of medicine to cause a patient's death (pp. 2230-33).

The second argument which supports the above claim is that causation and
agency make the cases of active and passive euthanasia morally different. Philippa
Foot has argued very well on the issue. Her argument makes a distinction between
active and passive euthanasia by stating that a death comes about through our
agency if we send someone poisoned food or cut him up for spare parts, but not
(ordinarily) if we fail to save him when he is threatened by accident or disease (Foot,
1984 /1994b, p.282). She furthermore states that the difference between act and
omission is in fact irrelevant to any moral issue except in so far as it corresponds to
the distinction between allowing something to happen and being the agent to whom
the happening can be ascribed (Foot, 1984 /1994b, p.281). She therefore challenges
the utilitarians, who place the whole moral significance of an action in its production
of good or harm, that they must treat the difference between initiating and allowing as
having no independent influence on morality. Philippa Foots suggestion is that in
active euthanasia the physician is cause and agent who performs the action of killing,
whereas in passive euthanasia the physician is neither cause nor agent to killing or
letting die a patient.
The third argument is that Rachelss claim unreasonably disregards the
distinction between ignorance of law and ignorance of fact. The distinction is widely
held decisive in every criminal or civil law texts and accordingly acted upon by courts.
Rachels uses ignorance of fact in his legalization proposal, therefore, the researcher
believes that the mention of ignorance of fact does not stand outside the context. The
ignorance of fact, if understood properly is that it speaks about the intentionality,
motive, and purpose. The law reflects the distinct moral force of intention that we
understand through our common experience. A crime committed intentionally
receives greater punishment than the same act done unintentionally. We recognize
differing "degrees" of homicide, and countless other crimes, depending upon whether
the act was done intentionally, knowingly, recklessly, or negligently. Such
differentiation continues through sentencing. Thus, the law treats the driver who
speeds recklessly but harms the darting child accidentally differently than the
depraved killer who deliberately plans to harm the child. However, Rachels may
object to this analysis that his position is moral and not legal. The response to such
claim is that though it is a fact that a legal action does not need to be a moral one and
vice versa, but the context in which Rachels states his position is a legal one. His
normative decisions are addressed to physicians and courts alike. And his proposal on
legalizing active euthanasia is also of legal nature. Therefore, Rachelss position is
not in a shape to avoid its legal criticism and therefore the adverse ramifications of
his position. Therefore, Rachelss removal of intention from judging an action
morally or legally is not only against the positive legal procedures but also against his
own legalization proposal where he states that a physician can defend his act of mercy
killing, besides other grounds, on the basis of ignorance of fact.
The third reason is that Rachels makes very superficial and shallow claim that
if a patient is dying and could be in fact cured and doctor leaves such a patient
without care and such a patient dies, and in the case killing and letting die would
make no difference. Rachels claims that in the same manner a physician lets a patient
die. Therefore, active and passive euthanasia are the same. Rachelss claim is very
irresponsible and subject to fallacies such as straw man fallacy, missing the point,
and equivocation; because terminating ordinary medical care when the patient is
potentially able to recover is not the subject matter of active euthanasia or passive
euthanasia. Of course, if a doctor lets a curable patient die by withholding,
withdrawing or terminating medical care in such a case the physicians act would not
be even an active euthanasia; his action will be a homicide, a crime. Rachelss by
arguing from such a proposition diverts the debate and leads his argument to straw
man fallacy; he therefore misses the point and leads to equivocation: passive
euthanasia therefore becomes neither mercy killing, nor letting die but a murder.
From the above reasons, it is clear that the intention is crucial in making a
moral and legal difference between two actions with similar consequences or
unintended consequences. The same is true about the two hypothetical cases of Smith
and Johns which Rachels gives in his argument. The cases are different, therefore
active and passive euthanasia are different.
The fourth reason is that Rachelss illustration of Smith and Johns in support
of his argument commits fallacy of weak analogy. Rachels hypothetical case as
mentioned earlier is called bare difference" argument of Rachels. The argument
contrasts two cases of Smith and Jones. The contrast is an attempt to show that two
different actions one killing and other letting die are morally the same. In fact,
the cases are supposed to show as presented by Rachels that the difference between
killing and letting die is irrelevant to any moral judgment. But the contrast fails to
make the point. Both the cases show the same result, however, the contrast is not
analogous with the actual case of euthanasia. The analysis of the case shows that in
both of these cases the victim is a person who is potentially able to live. In Smiths
case the victim is deliberately murdered and in Jones case the victim is intentionally
left to die. Comparing the same case with euthanasia, in active euthanasia a person
whose fate is not yet known whether he will live or die or at most he may be going to
die, is being killed whereas in passive euthanasia such a person is left to die.
Comparing case of Jones and passive euthanasia the analogy becomes problematic. In
Jones case the victim is a healthy young boy with a good potential for life, whereas
in passive euthanasia the patient is terminally ill with no hope of recovery. In Jones
case if help is extended to the victim, he could be saved, whereas, in passive
euthanasia even extending help would not make things better or rescue the dying
person from process of death. Furthermore, Unlike Jones cousin, the recipients of
passive euthanasia are not victims; they are autonomous agents who have the right to
refuse treatment. If a doctor administers treatment against the will of patient, he
infringes on the rights of the patient as a free agent and is guilty of assault and battery.
Thus in the case of passive euthanasia, the doctor is not allowed to help the patient
and should not be held morally responsible for the death of the patient. Jones has a
choice to save his cousin and does nothing while the doctor is unable to do anything
to save his patient because of the patients autonomy and right to refuse treatment.
Thus even though there is , on Rachelss formulation, no moral distinction between
killing and letting die there is a distinction between active and passive euthanasia.
The two cases are not analogous and the distinction between active and passive
euthanasia lies in the patients autonomy and ability to refuse treatment. Therefore,
the inference from killing and letting die to active and passive euthanasia does not
stand valid.
3.3.4. Criticism of that the Arguments in Favor of the Conventional View do not
Work
Rachels mentions that one often heard argument for the conventional view
goes like that in passive euthanasia, there is nothing that the doctor does which can be
called cause of death. The disease causes the patient to die, not the doctor. So how
can the doctor be held responsible for the death, if he doesnt even do anything?
The logical form of the argument according to Don Berkich is as follows:
1. Active euthanasia is doing something to bring about death.
2. Passive euthanasia is not doing anything
3. Doing something to bring about death is worse than not doing anything.
Therefore
4. Active euthanasia is worse than passive euthanasia (1, 2&3)
5. If active euthanasia is worse than passive euthanasia, then CDE is true.
Therefore
6. CDE is true (4&5) . ( Berkich , 2003 )
Rachels responses to above argument and shows that the argument in favor of
CDE is unsound. Rachels shows that premise 2 Passive euthanasia is not doing
anything and premise 3 Doing something to bring about death is worse than not
doing anything are false.

Passive euthanasia is not doing anything, as the premise 2 states in the
argument. But Rachels maintains that letting a patient die is also doing. Rachelss
argument is unsound due to two reasons: (1) the direct cause of death is different, in
the active it is the doctor an in the passive it is the disease itself; (2) Rachelss
argument is fallacious due to straw man fallacy.
The first reason is that the direct cause of death is different; in active
euthanasia it is the doctor as a human agent who actually kills the patient, whereas in
the passive euthanasia it is the disease itself. The distinction between active and
passive euthanasia is clear that causality of the death in active euthanasia is a lethal
injection whereas in passive euthanasia the cause of the death is disease itself. The
distinction pivots on the way we understand causality and culpability. In killing, the
cause of death is the lethal intervention. In allowing to die, the cause of death is the
natural biological process. When the cause of death is the impersonal force of nature,
no one can be held responsible. But if death results from the human action of
injecting or ingesting lethal medication, then someone can be held culpable. The
causality in killing and letting die cannot be the same; Daniel Callahan has put the
difference succinctly as follows:
[I]t confuses reality and moral judgment to see an omitted action as having
the same causal status as one that directly kills. A lethal injection will kill
both a healthy person and a sick person. A physician's omitted treatment will
have no effect on a healthy person. Turn off the machine on me, a healthy
person, and nothing will happen. It will only, in contrast, bring the life of a
sick person to an end because of an underlying fatal disease. (Callahan, 1992,
pp. 52-55)
The above case vividly shows that as far as the death of a patient is concerned
it is in active euthanasia, that a doctor does something which kills the patient and in
passive euthanasia the case is just not the same, therefore the premise 2 in the
argument is valid. The premise 3 is per se valid that doing something is literally
killing and killing is worse from not killing and it is even worse than letting die
because of the reason shown in this research, mostly where it is shown that Rachelss
argument that active euthanasia is more humane than passive euthanasia is criticized.
The second reason is that the misrepresentation of the case is evidently shown
in this matter. The AMAs statement does not state about doing and not doing. It
explains that not doing in case if the doctor foresees the death. But Rachels's rebuttal
relates to the case when the patient is suffering the curable diseases (Rachels, 1975/
1994a, p.118). Therefore, Rachels is committing straw man fallacy.
3.4. Criticism of Rachelss Arguments for Active Euthanasia
Rachelss arguments for active euthanasia are of types. The first type is based
directly on his biological and biographical distinction as elaborated in the conceptual
framework. The second type of arguments by which he supports active euthanasia are
those which show that the distinction between active euthanasia and passive
euthanasia is absurd morally. And wherever passive euthanasia is applicable, active
should be permissible as well. This has been shown in the second part of this chapter.
The first two types of arguments can be classified as indirect arguments. The third
type of arguments is Rachels's direct arguments as discussed in this part of the
chapter. The ethical arguments for and against euthanasia have remained largely
unchanged for centuries. These arguments can be organized under three themes:
autonomy, killing vs. allowing dying, and beneficence (Gula, 1999a, pp. 501-505).
Rachelss arguments are not different from these arguments; however his way of
presenting them is different.
Rachels believes that active euthanasia is morally justified in some instances
and that at least two strong arguments support this position. The first is the argument
from mercy; the second is the argument from the best interests and golden rule
(Rachels, 1981/ 1994b, p.146). He adds one more argument for the legalization of
active euthanasia based on the right to liberty (Rachels, 1983). Briefly, this argument
states that dying people should be free to choose euthanasia as a matter of personal
liberty.
The very crucial part of Rachelss argument for active euthanasia is that they
are interconnected in a way that no single argument stands on its own to support his
position. His first argument from mercy shows the problem of pure utilitarianism, to
remove such a difficulty, he moves to best interest argument, where he feels helpless
to support his best interest which he tries to support by the golden rule argument and
the golden rule argument ultimately depends on autonomy. Autonomy becomes
problematic and more problematic by his legalization proposal for active euthanasia.
Therefore, there are main three arguments as criticized in the following part of the
chapter.
3.4.1. Criticism of the Argument from Mercy
Rachelss position is that it is cruel and inhumane to refuse the plea of a
terminally ill person that his or her life may be ended to avoid unnecessary suffering
and pain. Allowing such a person to terminate his or her life is an act of
mercy. Rachels supports this argument by documenting various cases in which he
describes the suffering of terminally ill patients and suggests that their suffering could
be stopped by active euthanasia.
The above argument is similar to the first argument against CDE which shows
that active euthanasia is more humane than passive euthanasia. The response to that
argument is given in the respective place. The response, however, is not different
from the response given to the former argument under 3.3.1. Criticism of That Often
Active Euthanasia Seems More Humane Than Passive.
3.4.2. Criticism of the Best Interests and Golden Rule Argument
Rachelss argument from mercy is a utilitarian argument. Rachels is himself
uncomfortable with the pure utilitarian argument, therefore he suggests the best
interest and golden rule argument. He claims that the following argument is sound and
proves that active euthanasia can be justified:
If an action promotes the best interests of everyone concerned, and violates
no one's rights, then that action is morally acceptable.
In at least some cases, active euthanasia promotes the best interests of
everyone concerned and violates no one's rights.

Therefore, in at least some cases active euthanasia is morally acceptable.
(Rachels, 1981/ 1994b, p.149-150)
Rachels supports the above argument with golden rule argument. Rachels
relates the Golden Rule to active euthanasia by saying that if there are two choices to
die: (1) to die quietly, and without pain, from a fatal injection; and (2) to die of an
affliction so painful that for several days before death you would be reduced to
howling like a dog, with your family standing by helplessly, trying to comfort you,
but going through its own psychological hell. Rachels states that it is hard to believe
that any sane person, when confronted by these possibilities, would choose to have a
rule applied that would force upon him or her the second option. And if we would not
want such a rule, which excludes euthanasia, applied to us, then we should not apply
such a rule to others (Rachels, 1981/ 1994b, p.151-152).
There are three reasonable ways to argue against the Best Interests and Golden
Rule Argument and therefore rendering them invalid. They are: (1) the argument is
based on subjective moral judgment, failing the universalization test; (2) it may not be
in my own best interests or in the best interests of others for me to die; and (3) the
argument is based on indefensible autonomy.
Firstly, the best interest and golden rule arguments are based on subjective
moral judgment, therefore the arguments fail the morally universalization test and
become subject of partiality. The universalization test is crucial because Rachels
himself accepts categorical imperative and therefore he is supposed to be having no

objection if his moral position is subjected to such a test. If a person takes anything in
his own interest, it does not guarantee that such an act would be desirable to other
people. Similarly, not everything people would wish to have done to them is morally
appropriate. Put differently, people can dehumanize themselves and actually do so
in active euthanasia by intentionally killing themselves or by others intentionally
killing them. The golden rule argument fails due to its partiality and it fails the test of
generality. First of all if active euthanasia is accepted by it acceptance from some
patients and that does not make it generally acceptable. The approval is very
subjective in its nature. M. Cathleen Kaveny has suggestion also supports the above
position as follows:
The most pressing challenge facing opponents of assisted suicide or
voluntary euthanasia can be found in the faces of those who request such
practices in order to put an end to their suffering. They are pointing to their
own pain as a justification for carving out an exception to the general legal
and moral rule against intentionally killing the innocent. (Kaveny, 1997)
The closely connected to the above position is that the justification which some
terminally ill patients give for euthanasia need to be scrutinized. The researches
suggest that such approval of euthanasia is based mostly on the opinions of patients
whose decision power is clouded either by medication or depression. Hendin, Foley,
& White (1998b) have referred to theses researches which scientifically describe the
psychological conditions of terminally ill patients. The diagnosis of depression is
particularly important since like other suicidal individuals, patients who desire an
early death during a serious or terminal illness are usually suffering from a treatable
depressive condition (Harvey et al. & Ezekiel et al.). Although pain and other factors,
such as a lack of family support, may contribute to a patient's wish for death,
depression is the most important factor. In fact, researchers have found depression to
be the only factor that significantly predicts the wish for death (ibid.). Two-thirds of
patients requesting assisted suicide are depressed (ibid.) about the same percentage as
those who attempt or commit suicide unaided (Robins et al. & Barraclough et al.).
Hopelessness, the aspect of depression that helps distinguish depressed patients who
are suicidal from those who are not, has been shown to play a similar role in
predicting suicidal ideation in patients who are terminally ill (Harvey et al. ) ( pp.
243-70) . In face of all these evidences, Rachelss case again fails the test of
universalization which includes that the decision should be autonomous, but the
researches show that the euthanasia willing patients are not rationally autonomous,
they are either depressed or they are driven by other factors than reason.
Furthermore, it is important to elaborate on Kants categorical imperative,
which negates the conclusions of Rachels. For Kant, our rational wills are the source
of our moral duty, and it is therefore a kind of practical contradiction to suppose that
the same will can permissibly destroy itself. Given the distinctive worth of an
autonomous rational will, suicide is an attack on the very source of moral authority.
Consequently, disposing of oneself as a mere means to some discretionary end is
debasing humanity in one's person (as cited in Cholbi, 2004). Kant argued that taking
ones own life was inconsistent with the notion of autonomy, properly understood.
Autonomy, in Kants view, does not mean the freedom to do whatever one wants, but
instead depends on the knowing subjugation of ones desires and inclinations to ones
rational understanding of universally valid moral rules. (as cited in the New York
State Task Force on Life and the Law , 1994, chap.5)
Secondly, it may not be in my own best interests or in the best interests of
others for me to die. If I am willing to allow others to perform active euthanasia on
me and, by the Golden Rule argument, I'm willing to do so to them, I am mistaken in
my perspective and leaving out morally relevant information. Rachels's point that
once we are old what should be done to us could be objected by the similar questions.
"As I lie dying, will I be offered humane care, will I be done in too soon by some
expediency, or will I be subjected to terminal torture?(Vaux, 1989, p.29). Do
terminally ill patients really ask for euthanasia the research on the topic negates the
affirmation.
A new study published in the November 15 Journal of the American
Medical Association has found that most terminally ill patients would not
choose physician-assisted suicide or euthanasia to end their lives.
Interviews with 988 terminally ill adults and their primary caregivers
revealed that around one in ten people seriously considered using
physician-assisted suicide or euthanasia and that less than 6 percent had
seriously discussed the possibility or taken steps to commit suicide. The
researchers, led by Ezekiel J. Emanuel of the Department of Bioethics at the
National Institutes of Health, also found that those who considered either
option are affected by depression, feel unappreciated, and have significant

need for help with the basics of living. The study's authors warn that
doctors who receive requests for physician-assisted suicide or euthanasia
should not consider patients to be definite about their decisions. (Emanuel ,
2000, p. 1267 )
After presenting the above studies, it is contextually suitable to look into a
cited case of active euthanasia where a patient asks for lethal injection. Kuhse ( 1994)
reports the following case:
Mary F. was dying from a progressively debilitating disease. She
had reached the stage where she was almost totally paralyzed and,
periodically, needed a respirator to keep her alive. She was
suffering considerable distress. Knowing that there was no hope
and that things would get worse, Mary F. wanted to die. She asked
her doctor to give her a lethal injection to end her life. After
consultation with her family and members of the healthcare team,
Dr H. administered the asked-for-lethal injection, and Mary F.
died.( p. 295)
The case of Mary F. who was totally paralyzed and periodically needed a
respirator to keep her alive shows that she was kept alive by artificial means and
these artificial means of prolonging death could be desperate to the level that a patient
can ask for active euthanasia. The problem is if such a person was not kept alive in
the first place by artificial means such need and desperation would have not occurred.
The main problem with Rachels is that he does not write anywhere about the misuse
of medical technology.
Thirdly, both best interest and golden rule arguments are based on autonomy. The
related and separate argument from autonomy is repudiated in the next part of the
chapter. The repudiation of the autonomy argument invalidates both best interest and
golden rule argument.
3.4.3. Criticism of Rachelss Argument from Autonomy
Rachelss conception of biographical life entails that a human being is an
autonomous being; therefore, if a person autonomously chooses to end his or her life
then it is morally permissible. And that dying people should be free to choose
euthanasia as a matter of personal liberty. Rachels also supports his position by the
analogy to the law of suicide. The argument begins with the proposition that since it
is not unlawful for a person to commit or attempt to commit suicide, the law,
implicitly at least, recognizes the right of an individual to take his or her life. From
this premise it is argued that if an individual does have the right to take his or her life,
he or she should be able to seek the assistance of others in achieving this end (Rachels,
1983, p. 19). Likewise, Rachelss main arguments in favor of active euthanasia are
basically and essentially based on the consent of the terminally ill patient, that the
justification of such practice is based on the free will and autonomy of the patient and
furthermore on the joint consent of the other parties involved. Therefore, the
argument from autonomy in favor of voluntary active euthanasia stands as the
foundation of Rachelss thesis which according to him is based on two strong

arguments, the golden rule and the best interest arguments. The autonomy argument,
by and large, involves discussions on liberty, rights, self determination and
conception of autonomy itself. Rachels in his works refers to all these concepts to
gain more warranty for his argument.
The researchers position is that argument from autonomy fails to claim the
sufficient support to substantiate a pro-position for the approval of active euthanasia.
The reasons which support such a position are: (1) invalidity of civil rights claim; (2)
weak analogy between suicide and euthanasia; (3) unwarranted influence of patients
autonomy on doctors autonomy; and (4) unattainable autonomy of the terminally ill
patients.
3.4.3.1.Self-determination and Euthanasia
Among many grounds to claim that a person enjoys a right to euthanasia is
from self- ownership and closely connected to this is similar claim from self-
determination.
The self-ownership claim states that a person enjoys a right to euthanasia
because a person owns his body and hence such a person is morally permitted to
dispose his body as he wishes. The claim on Rachelss view is sound as long as such
giving away does not infringe anyone's rights. The claim from its nature is one of
those related to right of property and ownership. And the implication, from this view,
is that our relationship to our bodies is like that of our relationship to other items over
which we enjoy property rights. Therefore, we can dispose our bodies as we dispose
other owned things and objects. As a result, since property rights are exclusive
therefore others may not interfere with our efforts to end our lives. The concept of
self-ownership whether related to euthanasia or suicide is one of the famous
arguments. However, the very important factor is that the analogy between property-
ownership and self-ownership is that we cannot own ourselves the way we own
things which belong to us. There are two very important points which should be
considered; one is that we own things because they are metaphysically distinct from
us, whereas our bodies are not so. Even under all dualistic views of human nature,
our selves are not sufficiently distinct from our bodies to implicate any ownership.
Rachelss distinction of biological and biographical life is also one of such views; his
biographical life is necessarily connected to and dependent on biological life. Indeed,
the fact that certain ways of treating ordinary property are not available to us as ways
of treating our bodies, we cannot give away or sell our bodies in any literal sense,
suggests that self-ownership may be only a metaphor meant to capture a deeper moral
relationship (Kluge, as cited in Chobli, 2004, Libertarian Views and the Right to
Suicide, para.4). The other point is that even if we accept the self-ownership claim,
the claim from its implication will lead to extreme moral subjectivism. Acting out of
subjective moral discretion , even if it does not harm any one, may be somehow
acceptable in some case, however such case will not be sufficiently enough to make a
moral claim and subsequently will lack in becoming a legal position.
The right of self-ownership is closely connected to the right of self-
determination. It is a right to shape the circumstances of our lives so long as we do
not harm or imperil others. However, relating right of self-determination to
determining the circumstances of death is a different case. Because, it does not seem
to follow from having a right to life that a person has a right to death. The rights are
of two kinds: inalienable and alienable. Inalienable rights are those that by their
nature cannot be taken away, violated, or transferred from one person to another.
They are considered more fundamental than alienable rights, such as rights in a
specific piece of property. The right to life is inalienable, since in order for me to kill
myself, I must first renounce my inalienable right to life, which I cannot do (Feinberg
as cited in Chobli, 2004). John Locke has the similar views he states that in the
State of Nature no one has the right to take their own life, or assist in the death of
another individual (Locke, 2001, pp. 72-73).
Rachelss position on self-determination is however a confused one if a
holistic view of his thought is taken. His claim for autonomy and self determination
leads from two positions: biographical life and civil liberty.
From the point of biographical life it does not entail that a person who has lost
his biographical status could claim any inalienable and alienable right. As the
researcher has mentioned earlier while criticizing the biological and biographical
distinction that the distinction is slippery and leads to involuntary and non-voluntary
euthanasia. However, from the same perspective Morelands (1990) following
conclusion briefly shows the conceptual complications in Rachels:
According to Rachels, the rule not to kill is no longer morally relevant to
people without biographical lives. This is because the point of the rule is to
protect people with biographical lives. It would seem, then, that a person who
no longer has such a life -- who has no point of view -- is no longer included in
our duty not to kill. But if the person has lost the right not to be killed, it would
seem that other rights would be lost as well, since the right to life is basic to
other rights. In this case, it would be morally permissible to experiment on
such a person or kill him or her brutally. Why? Because we are no longer
dealing with an object that has the relevant rights. ( p. 74)
From the above analysis, it seems that Rachelss biographical life and autonomy
are in conceptual tension to lead to any clear position because of conceptual and
theoretical complications. Nevertheless, Rachelss claim from civil liberty is a clear
stand on the issue. However, it is practically and theoretically impossible to include
euthanasia in civil liberties; on the contrary, euthanasia by its nature can only claim
to be included in rights; and claiming euthanasia on the basis of rights is indefensible.
3.4.3.2. Analogy of Euthanasia with Suicide
Rachels attempts to defend his claim for active euthanasia by making the
suicide and euthanasia equal. He therefore makes an analogy between suicide and
euthanasia. When in fact, Rachelss analogy is weak and problematic. A crucial
question which needs to be addressed is what significance, if any, should be attached
to the fact that active voluntary euthanasia involves the direct assistance of a second
party. It could be argued that an important distinction exists between suicide on the
one hand, which is an autonomous and self-regarding act, and assisted suicide or
active voluntary euthanasia on the other, which requires the involvement and
assistance of a second party (Callahan,1989, pp. 4- 5) . This second party
involvement constitutes a crucial difference because the conduct changes from being
a purely private act to a form of public action with ramifications extending beyond
the parties involved. Moreover, it could be argued as well that if the argument for
active voluntary euthanasia is based on dignity of human freedom and self-
determination, then it is inconsistent to ask someone else to assist (Linacre Centre
Working Party, 1982, pp. 28-9).
3.4.3.3. Right, Liberty and Euthanasia
To return to the principle of self-determination, if one accepts the principle as
the basis for active voluntary euthanasia, it remains to be determined what legal status
should be given to such a right; should that be a basic human right or a legal right.
The recognition of the right to die as a human right would create duties on the part of
the state; it would not confer on individuals any legally enforceable right to active
voluntary euthanasia or impose any obligation on doctors to participate in its
administration. In light of this, it seems practically impossible for euthanasia to
happen, because euthanasia involves physicians who under such right cannot be
forced to involve with euthanasia practice.
The situation is more problematic where the right to die is expressed in terms
of a legally enforceable right. Apart from problems of definition, there are potential
difficulties in adopting a strict rights-based model as the basis for legalization of
active voluntary euthanasia. Although the notion of 'rights' is expansive and, in its
wider sense, can be used to encompass a variety of legal concepts, (Hohfeld , 1919,
pp. 6-7, 36-8) strictly speaking, rights, as distinct from liberties or privileges are
correlative with duties. Thus, the creation of any right to active euthanasia tends to
imply a corresponding duty on the part of someone to become actively involved in
bringing about death. Whereas, according to accepted principles of autonomy and
liberty, individuals should be free to pursue their own life choices, provided that this
does not violate the rights of any other parties. In promoting the self-determination
and autonomy of the patient, there appears the responsibility not to interfere with the
autonomy of others. In particular, doctors should not be required to abdicate their
autonomy in favor of that of the patient. The position of other parties, and their right
to remain free of involvement in the practice of active euthanasia poses a general
problem in any attempt of approving right to euthanasia as a claim right. Certainly in
the US constitutional context, the courts have already indicated that the recognition of
a constitutional right to physician assisted suicide does not entail any duty on the part
of any doctor (Compassion in Dying v. State of Washington, 1996).
Another possibility is for the right to active voluntary euthanasia to be framed
simply in terms of a right of one person to authorize another to kill him or her
intentionally and directly but without creating a right to demand such assistance.
There is broad agreement amongst euthanasia advocates that it would be
inappropriate to impose a duty on any person to take the life of another. Although
such a duty would uphold the autonomy of the patient who requests assistance, it is
recognized that it would be an unjustifiable interference with the autonomy of others.
It is primarily to avoid the implication of any such duty and the resulting infringement
of the autonomy of other parties that a strictly rights-based model has been widely
rejected as an appropriate basis for the legalization of active voluntary euthanasia
(Trowell, 1973, pp. 116-21). Therefore, argument from autonomy involves rights and
duties , and a terminally ill patients autonomy cannot be realized unless autonomy of
other parties are endangered, and doing so is not possible by any rights based model
for euthanasia.
3.4.3.4. Autonomy of Patients
The further objection to the argument based on autonomy is about autonomy
itself and that is the consent of the patient on termination of life actively. The
concerns involved are various such as how can it be sure that the person in condition
which requires active euthanasia could have a free will; there could be concern that
the use of a pain killer in a dying individual could so cloud his conscious response
that he might not in his dying moments be in a position to make decisions ( Koop ,
1989a, p.73). The consent therefore received could not be accepted as reasonable and
sound to substantiate such a decision.
To support the above concern on practical grounds, the researches show that
most of the patients who wish for death are depressed persons. The patients who
desire an early death during a serious or terminal illness are usually suffering from a
treatable depressive condition. Although pain and other factors, such as a lack of
family support, may contribute to a patient's wish for death, depression is the most
important factor. In fact, researchers have found depression to be the only factor that
significantly predicts the wish for death. Researches show that two-thirds of patients
requesting assisted suicide are depressed about the same percentage as those who
attempt or commit suicide unaided. Hopelessness, the aspect of depression that helps
distinguish depressed patients who are suicidal from those who are not, has been
shown to play a similar role in predicting suicidal ideation in patients who are
terminally ill ( Hendin, Foley, & White, 1998, p. 243-70 ) . Paul R. McHugh argues,
but when it comes to terminally ill patients, "outside forces" are likely to "overwhelm
the self, rendering it vulnerable to unreflective impulses" (McHugh, 1999, p. 5-6).
Due to these factors, realization of patients true autonomy becomes unattainable.
Aristotle rightly points out the difficulty of making a rational decision while in the
grip of pain and suffering. He describes the case of physicians that though they are
experts on matters of life and death; they even ask other physicians to treat them
when they fall sick. Aristotle states:
Doctors themselves call in others doctors to treat them when they are sick,
and trainers call in other trainers when they are exercising, their
assumption being that they are unable to judge truly because they are
judging about their own cases, and while in pain. (Aristotle, 2000, iii
16.1287a41 b3)
Besides above grounds, Rachelss argument for active euthanasia is
unnecessary. There is practically no such a need to resort to active euthanasia if
medical technology is not allowed to mishandle the patients and prolong their dying
process. On the other hand if a person is being kept alive by artificial and
extraordinary means, in such a case the treatment can be withdrawn. And in cases of
patients whose life is painful, their problem can be successfully resolved by the pain
medication and wider use of principle of double effect. Therefore, as such, active
euthanasia is indefensible because of serious inadequacy of autonomy argument.

3.5.Criticism of Rachelss Proposal of Legalizing Active Euthanasia
Rachels while using the fundamental procedure in the criminal trials in
American courts proposes a legal scenario in which there is legally a successful
possibility of making active voluntary euthanasia a reality without any adverse
repercussions to the physician who performs such an act. He elaborates that under his
proposal, someone charged with murder could also plead mercy killing; and then if it
could be proven that the victim while competent requested death, and that the victim
was suffering from a painful terminal illness, the person pleading mercy killing would
also be acquitted (Rachels, 2003). Rachels while explaining the above procedure
mentions that under the above proposal no one would be "authorized" to decide when
a patient should be killed. He adds that there are no committees to be established
within which people may cast private votes for which they are not really accountable;
people who choose to mercy kill bear full legal responsibility, as individuals, for their
actions (Rachels, 2003). Rachels further explains that by following the proposal we
would rely on the good sense of judges and juries to separate the cases of justifiable
euthanasia from the cases of unjustifiable murder, just as we already rely on them to
separate the cases of self-defense and insanity and coercion (Rachels, 2003).
Rachelss proposal of legalizing active euthanasia is problematic and
unpersuasive. After analyzing his proposal from the legal and practical points, his
proposal turns out to be impractical. The main problems in the proposal are
enumerated as follows:
(1). The proposal fails to provide clear guidelines. The proposal has very
ambiguous guidelines for both doctors and courts. For example, Rachels
recommends doctors to recourse to ignorance of fact and recommends judges that
doctors who have committed mercy killing could be acquitted on basis as judges
consider in criminal trials such as grounds of insanity. This ambiguity renders the
proposal unclear , therefore not worthy of adaptation.
(2). The proposal suggests that the mercy killing act would be a murder and could
deserve a trial where a doctor can defend his action. This is practically very
difficult, but impossible. The impossibility specially arises when the murdered
person is killed and there is no one left to follow his killing or those who follow
have vested interests.
(3). Rachels is very naive about homicide and criminal law procedures. He
suggests that when there will be no one to follow the murder case as guardians
will give consent positively, the doctor will not be bothered by any court trial.
Rachels ignores the role of the state and police. Rachels confuses criminal trial
with civil trial.
(4). The other problem is if such proposal accepted who would be ready to face
the trial and jury after every act of mercy killing. Would not such a doctor be
scared who could expect anything from jury in absence of any guidelines and
legalized procedures. There will not be many doctors available on earth who
would be ready to go for murder trial after every euthanasia, and such a way will
easily open way for corruption of the physicians who are historically thought to
be humane.
(5). The biggest problem which the proposal fails to deal with is that on one hand
Rachels dismisses any committees which could decide the euthanasia, whereas on
the other hand he leaves the matter unto doctors that they could defend
themselves on commonsense or ignorance of fact, which gives an easy hand to a
doctor to kill people without any requirements.
3.6. Modern Advanced Medical Technology and Euthanasia
This research used broad construal definition of euthanasia for the sake of
convention and criticism, however the researcher agrees only on the narrow construal
definition of euthanasia which includes only active euthanasia as euthanasia. And
active euthanasia should be prohibited. To support such a position, the researcher
starts with the propositions: (1) that among moral hazards of advanced medical
technology is that it allows prolonging of death; (2) the cases of passive euthanasia
are the cases of the natural state of extinction and thought to be passive euthanasia
due to inappropriate use of advanced medical technology; and (3) the need of active
euthanasia as defended by Rachels due to some case studies of patients is also un-
defendable due to two reasons: (I) that the cases are actually mishandled by doctors
due to misuse of medical technology by prolonging life of dying patients and (II) if
there are terminally ill patients in anticipation of death and living in painful state ,
such patients could be given pain killers to get their pain under control even though
such medication shortens their life due to the side affects of such medication.
Therefore, Rachelss interpretation of active euthanasia as killing and passive
euthanasia as letting die is a false dichotomy.
In the following part of the chapter, the researcher will elaborate on the above
propositions respectively.
3.6.1. Moral Hazards of Modern Advanced Medical Technology
The most crucial and serious part related to euthanasia is the role of modern
advanced medical technology; and Rachels has almost left it untouched. He focuses
on the problem of those suffering in some ailment and focuses on the solution of such
cases. Whereas, the beginning and causes of problems remain untouched in Rachelss
thought; he apparently has no suggestions on that part to medical and legal authorities.
However, he has suggestions to both doctors and courts on the ways and methods of
how terminally ill patients could be killed.
As a matter of fact, modernity and advance of science and technology, besides
other goals, remain centered to one main issue and that is discovering natural causes,
and devising technological tools and machines, which could allow imitation of natural
processes and with higher ambition of bringing nature ultimately under control. On
one hand the ambition has brought comfort and progress to humanity in various ways,
and on the other hand the same science and technology has brought hazards and
misfortune to humanity in various domains on variety of levels and degrees. The
medical profession could be treated as the most beneficiary of the modern science,
however the misplaced use of medical technology has also created many ethical
problems and among such problems is the issue of euthanasia. Joseph Fletcher has
put the case succinctly: Most of our major moral problems are posed by scientific
discoveries and by the subsequent technical know-how we gain, in the control of life
and health and death. Ethical questions jump out at us from every laboratory and
clinic (Fletcher, 1987/ 1989, p. 88).
The involvement of medical technology with death and issue of euthanasia
particularly stems from two main facts. The first reason is that, whereas in the past
most people died in their homes, the vast majority now dies in institutions governed
by the medical profession. In the United States and likewise in other developed
countries, during the twentieth century, death moved out of the home and into
medical institutions. In 1983 President's Commission for the Study of Ethical
Problems in Medicine and Biomedical and Behavioural Research, a report about US
stated that: As medicine has been able to do more for dying patients, their care has
increasingly been delivered in institutional settings. By 1949 institutions were the
sites of 50 per cent of all deaths; by 1958 the figure was 61 per cent; and by 1977
over 70 per cent. Perhaps 80 per cent of the deaths in the United States now occur in
hospitals and long-term care institutions, such as nursing homes ( 1983, p 17). The
same trend is being reported in other countries, briefly, the developed countries top
the list. (Bryant, 2003, p.205). Sharon R. Kaufman comments that Today, more
Americans die in hospitals than anywhere else, and the most frequent response to
critical illness there is to try to stave off death with the most sophisticated
technological means available. Approximately one-quarter of all hospitalized patients
are treated in intensive care or cardiac care units before they die(Kaufman, 2005,
pp.1-8). Likewise, the other countries follow the same road; therefore death is now
very much a medical business. The other reason is that the fact that most people now
die in hospitals has another side to it that modern hospitals usually provide high
technology medicine with sophisticated resuscitation equipment and life sustaining
machinery. The intensive care and employment of high technology complicates the
process of dying and in fact prolong the process of dying in an unnatural way.
Accordingly, Max J. Charlesworth (1989) has depicted the scene as follows:
In a sense the high technology hospital creates its own special ethical
problems simply because it has the technology to artificially sustain and
prolong the lives of gravely disabled newborns and others. The Karen Ann
Quinlan case was a product of such a hospital situation in that since the
life-sustaining technology was at hand it had to be used. Had Karen Ann
been sent to a remote country hospital, nature would have quickly taken its
course and she would have died. What is 'ordinary' run-of-the-mill
treatment in a large high technology hospital is of ten quite 'extraordinary'
beyond-the call-of-duty treatment in a smaller country hospital. In
hospitals with sophisticated medical technology physicians would be
culpably negligent if the complex medical technology were not used. As a
result the tendency in such hospitals is to sustain people's lives just
because the technology is available. (pp. 64-65)
As a result, the use of high technology has given the sense to humans that they
are no more helpless onlookers in the presence of death; they are now increasingly
able to intervene in the process, using technological resources to direct or delay the
inevitable (Veatch, 1989, p. 2) . Furthermore, the human medical interventions have
interrupted the natural death process to such an extent that very few illnesses can be
said to have a natural course (Omar, 1993, p. 613). These interventions have lead to
prolongation of death and suffering. With this in mind, Omar Mendez states:
Sometimes, because of legal issues, we are driven to the point of doing the inhumane
by artificially maintaining a body that has no cognitive functions despite the
family's requests and even the previously expressed wishes of the patient (Omar,
1993, p. 614).
The abovementioned well documented scenario which takes place in medical
setting encourages that a dying person should be first of all hospitalized, secondly
such a person should be kept under high intensive care laid on life sustaining
machines, and thirdly such a person should not be given chance to natural way of
passing away. These reasons stand at the root of the problem of euthanasia; and they
are totally ignored by Rachels. Rachels has nothing to say about it. This medical
situation which is actually a set of unnatural settings has made the case of terminally
ill persons so overwhelming on every front that has made Rachels and his proponents
surrender before its inevitable demand of killing of mishandled and medically over-
treated patients. The unfortunate picture of these patients which emerges because of
the given reasons, is on an emotional level being the main drive behind the euthanasia
movement and rationalization of mercy killing; the picture, being artificial and mess,
provides arguments which are misguiding and compelling to mobilize support for
active euthanasia. In other words, this intellectual helplessness in face of the
circumstances is a vivid description in what Van Den Haag acknowledges:

More and more people reach advanced age. But for many, disability
makes life a burden. Yet even when life is no longer desired, or
consciously experienced, medicine can now prolong it. Although still
fallible, diagnoses have become far more reliable than in the past;
prognosis is fairly certain. Miracles--medical or religious--are rare. It is
reasonable, then, to allow physicians to actively help end life when the
patient so desires.... We should no longer ask whether assisted suicide, or
mercy killing, should be allowed, but rather under what conditions.
(Carr,1995, pp. 50-51)
Alongside, the abovementioned surrender of intellectuals to the circumstances,
the desperation of terminally ill patients who are kept alive against their wishes, had
they were not kept artificially alive, they would have died, is not less at all. The
desperation could be understood by the deaths of Rev. Henry Van Dusen and his wife,
Elizabeth. Several years ago, the Rev. Henry Van Dusen and his wife, Elizabeth, both
of them in pain and with no prospect of recovery, joined in a suicide pact. The deaths
were front-page news in The New York Times and most other newspapers because
Van Dusen was president of Union Theological Seminary and one of the most
respected theologians in the world. In a suicide note, Elizabeth Van Dusen wrote:
There are too many helpless old people who, without modern medicine, would have
died, and we feel God would have allowed them to die when their time had come"
(Carr, 1995, pp. 50-51).

As indicated above, the terminally ill patients whose death is unnecessarily
prolonged are unfortunate cases of mishandlement of advanced medical technology.
The terminally ill patients whose recovery is not possible would have rather died
naturally, had they not artificially kept alive. Furthermore, it is evident that a need for
active euthanasia stems from the misuse of medical technology itself. The question
arises about those terminally ill patients whose recovery is unattainable and there is
no cure for them; are such patients suitable subjects for euthanasia, whether active or
passive,; the researchers answer is of denial. Because, they are not subject to either
killing, active euthanasia, or letting die, passive euthanasia. Because, passive
euthanasia is not letting die therefore it is not euthanasia.
3.6.2. Passive Euthanasia is not Euthanasia / Letting Die
The passive euthanasia, on Rachels's formulation, is defined as terminating or
withholding or withdrawing the treatment and which eventually leads to the death of
a person. The definition can be confusing that if ordinary medical treatment which
can benefit a patient is withdrawn, withheld or terminated, to researchers
understanding that kind of action is also active euthanasia. Rachels has also
misunderstood passive euthanasia in these terms; according to Rachels, passive
euthanasia means letting die. The statement of AMA is somehow very careful
understanding of the case, it states explicitly killing of patient is prohibited and such
formulation can be easily classified as active euthanasia and on the other side it states
that extraordinary treatment can be terminated if such treatment is not helpful. The
case therefore if treated as passive euthanasia deserves a careful definition: that

passive euthanasia is withholding, withdrawing or terminating medical treatment
from those patients to whom such treatment is useless or extraordinary. On this
understanding the passive euthanasia is not euthanasia it is just that the death works
its way. As an illustration, Daniel Callahan (1992) gives the following interesting
comment:
[I]t confuses reality and moral judgment to see an omitted action as having the
same causal status as one that directly kills. A lethal injection will kill both a
healthy person and a sick person. A physician's omitted treatment will have no
effect on a healthy person. Turn off the machine on me, a healthy person, and
nothing will happen. It will only, in contrast, bring the life of a sick person to
an end because of an underlying fatal disease. (Pp.52-55)
Therefore, the researcher maintains that passive euthanasia as widely known as
letting die is misrepresentation of the actual scenario in which a patient takes course
to his final exit without prolonging the process of his dying by using life sustaining
high technology and unaffordable burdens of medical care and artificial means of
maintaining biological processes. Similarly, when a patients condition is such that it
is not reasonable to hope that any medical procedures or treatments will save his life,
a failure to implement the procedures or treatments is not euthanasia. If the person
dies, this will be as a result of his injuries or disease and not because of his failure to
receive treatment (Gay-Williams, 1979/1989, pp.97-98).
The real and actual case of euthanasia is only active euthanasia. Active
euthanasia is killing a terminally ill patient to put end to his suffering. The point is
that is there really a need for such action on the part of a doctor, the simple
understanding of the case is negative. The negation of such a need is backed by
reasons: (1) a terminally ill person whose dying process is prolonged by life
sustaining medical technology and extraordinary means is most of the time thought to
be subject of active euthanasia, to avoid involvement of euthanasia such a person
should not be kept alive by life sustaining and extraordinary means against his wish ,
if the suggestion is followed there will not arise any need of actively killing such a
person and death will happen naturally due to illness, therefore active euthanasia will
be avoided. The cases which are most of the time illustrated to be subject of active
euthanasia are the cases actually mishandled by medical technology (2) the other
reason is that even if extraordinary medical treatment is terminated and life sustaining
equipments are disconnected , there is possibility of pain and suffering therefore
active euthanasia can put end to such a pain, however the case is not so that only
option of active euthanasia can put end to the problem, such persons suffering and
pain can be controlled by medicine and palliative care , the medication besides
soothing the pain may shorten life as a side effect, but such side effects are not
intended they are by-products , therefore the option of active euthanasia can be
avoided.
In short, if passive euthanasia means letting die , then there is no difference
between killing and letting die: because if a curable patient is not treated medically
such negligence is not different from killing. On the contrary, if passive euthanasia
means discontinuing useless and extraordinary medical care from an incurable patient
such termination of medical care is neither killing nor letting die. Therefore, on this
formulation passive euthanasia is not euthanasia. The question arises then who are the
subjects of active euthanasia; the researcher response is that none but those whose
death is prolonged, those who would have died naturally if not mishandled by
extraordinary, useless, and futile medical technology.
3.6.3. Active Euthanasia is Mishandling of those whose Death is Prolonged
The need for active euthanasia, if there is any need, which the researcher
thinks that there is not, is actually a consequence of mans mishandling the natural
laws within the medical sciences. The actual natural law of medicine is that the
living ought never to be treated as if they were dying, nor the dying as if they were
living( Vaux, 1988/ 1989, p.32). The law has been adversely affected by the misuse
of advanced medical technology. The crucial shortcoming in Rachelss thought is that
he tries to find the solution for mishandled patients to stop their suffering, but,
deliberately, ignores the causes of such suffering. He has no suggestions to doctors
not to modify nature and he has not made any criticism against that and on that base
he argues that death should be also made in an unnatural way. The problem as such
creates a dilemma for more nature loving people that how could they allow doctors to
modify nature and then plead for nature to run as unhindered. The proper way is that
to get it right in the beginning and it will be right in the end. And if we get it wrong in
the beginning then we have to commit another wrong in the end to make it look better,
we cannot get it right in the end when the whole matter is based on a wrong and
mistaken foundation. The mishandling of patients by employing advanced medical
technology is succinctly shown by Kenneth L. Vaux (1988/ 1989) as follows:

In recent years the qualities that morally distinguished the living from the
dying have been blurred. With our life-prolonging techniques and
medications, we have transformed death; we have taken it out of the acute,
natural, and non interventional mode and made it more into a chronic,
contrived, and manipulated phenomenon. Deaths as inevitable as Debbie's
have been protracted by a range of interventions, including chemotherapy
(disrupting the cellular-pathogenic process), analgesia (altering the release
of natural body endorphins and narcotics), the administration of
intravenous fluids and nutrients, and hospitalization itself. Logically and
emotionally, we cannot intervene at one phase and then be inactive at
another, more painful phase. We cannot modify nature and then plead that
nature must be allowed to run its unhindered course. (p.32)
As indicated above, the need for active euthanasia is the one artificial. The
doctors at one phase start prolonging death and at the point when the prolongation
becomes costly on all fronts such as suffering and financial expenses then disposal of
the patient in an unnatural way becomes eminent.
The above problem which shows the role of advanced medical technology in
worsening the condition of dying people, can be well illustrated by the most famous
and well documented cases debated in the history of euthanasia: Karen Quinlan,
Nancy Cruzan, and Terri Schiavo. The 21-year-old Karen Ann Quinlan collapsed at a
party after swallowing alcohol and the tranquilizer Valium on 14 April 1975. Doctors
saved her life, but she suffered brain damage and lapsed into a "persistent vegetative
state." She remained in a coma for almost 10 years in a New Jersey nursing home
until her death in1985 (Koop, 1976/ 1989b, pp. 33-42). Like Karen Ann Quinlan,
Nancy Cruzan became a public figure after entering a persistent vegetative state. A
1983 auto accident left Cruzan permanently unconscious and without any higher
brain function, she was kept alive only by a feeding tube and steady medical care.
The Cruzans stopped feeding Nancy in December of 1990, and she died later the
same month (Crigger, 1990. p. 38). On 25 February 1990, 26-year-old Terri Schiavo
suffered severe brain damage when her heart stopped for five minutes. Schiavo spent
the following years in rehabilitation centers and nursing homes but never regained
higher brain function. In 1998 her husband, Michael Schiavo, filed a legal petition to
have Schiavo's feeding tube removed, saying that his wife had told him before her
medical crisis that she would not want to be artificially kept alive in such a situation.
After long court battle, in March of 2005 Schiavo's feeding tube was removed, and
after two weeks without food and water, Schiavo died of dehydration on 31 March
2005.( Schiavo Case, 2007, p. 43060). These cases vividly show that how the death
of these people was prolonged for years and how they were kept alive by artificial
means either in a coma or in a persistent vegetative state. The unfortunate situation of
these terminally ill patients is very clearly stated by John J Paris (1997):
We have come to believe that the "miracles" of modern medicine are able
not only to defeat disease but to conquer death. With the rise of
technological medicine, lives that once were beyond rescue can now be
saved. Sometimes, however, that success comes at too great a price: a life
of suffering, pain and despair. Patients like Karen Ann Quinlan or Nancy
Cruzan may now lie trapped by a halfway technology, one that can ward
off death but not restore health, in a situation worse than death itself--an
endless prolongation of their dying. (pp. 11-14)
There was not such a need to use medical technology to prolong the process of
death the mostly it happens almost at the will of the physician (Koop, 1976/ 1989a,
p.72) and such persons could have died easily in a natural way than becoming the
problematic. The biological and moral hazard which advanced medical technology
has brought seems unresolved problem to many and the same thinking is behind those
who favor active euthanasia. The reason which they give behind their stand point is
that since misuse of medical technology has created the problem, therefore it is
unavoidable to surrender to the consequences. The problem with this argument is that
instead of correcting the use of medical technology these people while feeling
helpless before the use of medical technology, favor the active euthanasia. Gerald A.
Larue (1989 ) has drafted the following statement on the same lines. He says:
We acknowledge that techniques developed by modern medicine have been
beneficial in improving the quality of life and increasing longevity, but they
have sometimes been accompanied by harmful and dehumanizing effects.
We are aware that many terminally ill persons have been kept alive against
their will by advanced medical technologies, and that terminally ill patients
have been denied assistance in dying. In attempting to terminate their
suffering by ending their lives themselves or with the help of loved ones not
trained in medicine, some patients have botched their suicides and brought
further suffering on themselves and those around them. We believe that the
time is now for society to rise above the archaic prohibitions of the past and
to recognize that terminally ill individuals have the right to choose the time,
place, and manner of their own death. (p. 160)
As mentioned above, the Gerald A. Larues statement, it is quite evident that
those patients who are treated as the subjects of active euthanasia are actually those
case who are medically mishandled. The problem which seems is that cases which
deserve to be treated as cases which should be left on their own and intervened
fruitlessly and instead of life, death is being prolonged and once the case becomes
problematic the active euthanasia is being sought. The researcher thinks that instead
of reasoning for active euthanasia, it would be far better to reason against the
inappropriate use of medical technology. If biomedical acts of life extension become
acts of death prolongation, we may force some patients to outlive their deaths, and we
may ultimately repudiate the primary life-saving and merciful ethic itself (Vaux,
1988/1989, p.32).
In light of all the above details, the researcher thinks that AMAs statement on
euthanasia is valid. The statement makes a distinction between intentionally killing
and withholding extraordinary medical treatment. Moreover, the AMAs position
implies that the patients should not be intentionally killed and extraordinary medical
treatment can be withdrawn or withheld by the permission of the patient or the
hopeless condition of the patient by the permission of his legal guardians.
Furthermore, the above findings also lead to the conclusion that Rachelss
categorization of active and passive euthanasia into killing and letting die is a
false dichotomy. Rachels gives two choices to terminally ill patients: either killing or
letting die, and prefers killing to letting die. Whereas the researcher thinks that both
of these choices killing and letting die are irrelevant. The researcher, in light of the
above details, thinks that there is only one choice: (I) to stop prolongation of death
by the excessive and misuse of advanced medical technology, (II) to allow
termination of extraordinary medical care from terminally dying persons and, (III) to
allow use of pain medication by following legitimate procedures.

CHAPTER FOUR
Conclusion
This research demonstrates that James Rachelss defense of active euthanasia is
conceptually, theoretically, practically, and normatively unjustifiable. Rachelss
position on euthanasia is widely known as libertarian approach in contrast to the
traditional doctrine of euthanasia (TDE) or conventional doctrine of euthanasia (CDE).
The American Medical Associations (AMAs) position is in favor of the traditional
doctrine. The traditional doctrine makes a distinction between active and passive
euthanasia and prohibits the first and allows the latter. Whereas, Rachelss approach
debunks the distinction and treats passive euthanasia unnecessary and painful; and
prefers the active euthanasia. Rachels attempts to support his position by three ways: (1)
by developing a set of concepts, (2) by dissolving the distinction between active and
passive euthanasia, and (3) by arguing for active euthanasia. Furthermore, he proposes
a proposal on the legalization of active euthanasia.
In the outset of this research a clear understanding of euthanasia is sought by
analyzing a bunch of various definitions of euthanasia. The study shows that there are
two different usages of the term, euthanasia: narrow construal of euthanasia, which
refers to mercy killing or active euthanasia; and broad construal of euthanasia, which
refers to both active and passive euthanasia. Rachels adopts the broad construal of
euthanasia, and includes suicide and assisted suicide within his definition. Rachelss
definition is unacceptable, conceptually unjustifiable, and most confusing, because it
violates all the demarcations between euthanasia, suicide, assisted suicide, and
Conclusion 123
physician assisted suicide. Contrary to Rachels, the researcher agrees only with the
narrow construal of euthanasia, i.e. active euthanasia. The researchers definition of
euthanasia is: intentionally causing a terminally ill persons death by performing an
action. The definition is based on the facts that: (1) the death is caused by an agent
(human) instead of the subject (the patient), (2) the causing of death is intentional, (3)
the death is caused either by the request of the subject or the state of being of the subject
to make it different from a pure homicide (4) the death is caused by commission or
action and (5) the subject is terminally ill. As a result, passive euthanasia is expunged
from the definition because euthanasia means the intentional, mercy killing; and in
passive euthanasia intentional killing is not part of the withholding or withdrawing the
unnecessary and extraordinary medical treatment. Therefore, the researchers
definition includes only active euthanasia mercy killing as euthanasia. The definition
excludes: suicide, assisted suicide, physician-assisted suicide and passive euthanasia.
The reasons behind not considering passive euthanasia as euthanasia is due to: (1) the
death is natural, and not artificial (2) the death is not caused by action of any agent. The
suicide, assisted suicide, and physician assisted suicide are excluded due to: (1) the
death is not caused by an agent other than the subject. The very integral factor of the
notion of euthanasia is being killed by some agent (person) instead of the subject.
The historical sketch of euthanasia as detailed in this research shows that
problem of euthanasia has a long history of philosophical discussion; however, most of
the discussion revolves around the issue of suicide. The late twentieth century shows a
divide between suicide and euthanasia. Both these subjects become separate along with
their subject matter and arguments; although there is an unavoidable overlap between
Conclusion 124
them. The peculiarity of euthanasia is because of its relatedness to medical profession
and legal issues. The issue of euthanasia in its essential relation is practically connected
with medicine; it has brought the medical profession in question. The defenders of
active euthanasia suggest to redefine the profession not only as life saving but also as
life taking. Similarly, the issue has brought in debate the rights, duties, and autonomy
of both terminally ill patients and physicians. Due to the crucial touch of euthanasia to
medical profession the American Medical Association (AMA) announced its position
on the issue of euthanasia. The AMAs statement prohibited the intentional termination
of the life of one human being by another, mercy killing and allowed the cessation of
the employment of extraordinary means to prolong the life of the body when there is
irrefutable evidence that biological death is imminent. Rachelss interpretation of the
statement is that it supports passive euthanasia and opposes active euthanasia. Rachels
understands by active euthanasia killing and by passive euthanasia letting die.
Contrary to Rachels, the researcher disagrees on such categorization. The researcher
thinks that the statement refers to narrow construal euthanasia. Because, the cessation
of the extraordinary means of medical treatment does not amount to letting die.
Therefore, Rachelss interpretation is both conceptually and practically unjustifiable.
The chapter two of this research deals with Rachelss thought on euthanasia in
a detailed form. The ideas are grouped in three categories: conceptual framework,
arguments for absolution of the distinction between active and passive euthanasia, and
arguments for active euthanasia including the proposal on legalization of active
euthanasia, respectively. Rachels is a moral, utilitarian philosopher; while elaborating
his thought on euthanasia, he refers directly and indirectly to his conceptual framework
Conclusion 125
which permeates all of his arguments. Rachelss conceptual framework deals with
three distinctions: (1) biological and biographical life, (2) killing and letting die, and (3)
ordinary and extraordinary medical treatment. Rachels attempts to show that there is
morally no difference between active and passive euthanasia and where passive
euthanasia is appropriate, active should be allowed too. He challenges CDE for several
reasons: (1) active euthanasia is in many cases more humane that passive euthanasia, (2)
the conventional doctrine leads to decisions concerning life and death on irrelevant
grounds, (3) the doctrine rests on a distinction between killing and letting die that itself
has no moral importance, and (4) the most common arguments in favor of the doctrine
are invalid. Furthermore, Rachels explicitly supports active euthanasia. Rachels states
three main arguments: (1) the argument from mercy; (2) the argument from the best
interest and the golden rule; and (3) the argument from autonomy. And finally, he
proposes a modest proposal for the legalization of active euthanasia.
The criticism of Rachelss thought on euthanasia is the subject of chapter three.
The research analyzes Rachelss thought in accordance and order of the preceding
chapter. The chapter in argumentative and critical ways shows how Rachelss claims
are unjustifiable on all fronts: conceptual, theoretical, practical, and normatical.
The researcher criticizes the conceptual framework which comprises of
distinctions, and demonstrates that it has various problems which are reasonably not
enough to support the soundness of Rachelss position and that of arguments which
mainly draw on such distinctions.

Conclusion 126
Rachelss first distinction, biological and biographical life, holds that biological
life is ethically unimportant, whereas biographical life is important and relevant.
Rachelss support for active euthanasia is largely based on the distinction. The research
shows that the distinction does not provide a valid foundation or criteria for the
permissibility of active euthanasia. The distinction is rather inadequate due to: (1)
reductive fallacy oversimplification; (2) slippery slope and (3) inconsistency with the
main arguments of Rachels. The distinction commits reductive fallacy, because it
reduces human person to some functions and therefore divides a human entity into a
human being or biological life and human person or biographical life. The research
shows that such distinction is possible conceptually and not physically. The distinction
is both conceptually and practically unjustifiable: conceptually because it implies that
besides terminally ill patients, many persons like mentally ill and retarded, drug and
alcohol addicts, patients with Parkinson's and Alzheimer's diseases, and the comatose
are not persons; and practically because the distinction entails the consequences which
hardly seem to escape being the easy target of slippery slope; it leads to permissibility
of not only voluntary active euthanasia, but non-voluntary and involuntary as well,
because if having just a biological life without biographical life is a valid criterion
for euthanasia then the consent of terminally ill becomes irrelevant. Therefore, the
distinction defines a human person in way which is not coherent with the main
arguments of Rachels such as best interest and golden rule argument and argument
from autonomy, which are based on patients consent and autonomy. Therefore, the
distinction becomes irrelevant to Rachelss main arguments for active euthanasia.
Nevertheless, the distinction if restricted to painful and suffering terminally ill patients
Conclusion 127
who are kept alive by artificial means makes some sense, however, in such a case
killing actively is not the only option, the extraordinary treatment can be terminated.
Therefore, such a distinction deserves to be shunned in face of its inadequacy.
Rachelss second distinction, killing and letting die, maintains that there is
morally no distinction between killing someone and letting someone die. Rachelss
killing means active euthanasia and letting die passive euthanasia; therefore active
and passive dichotomy is a distinction without difference. The distinction pervades his
arguments from mercy and bare difference. Rachels illustrates his point by a
hypothetical example of Smith and Johns; Smith kills his cousin and Johns watches his
cousin die without extending any affirmative assistance. The research shows that the
distinction is: (1) irrelevant, (2) extraneous to the medical profession, and
methodologically degressive. The irrelevance of the distinction to euthanasia is that it
is not the case that doctors let the patient. The AMAs statement actually holds that if
the medical treatment seems extraordinary and unbeneficial, in such a case the patient
has choice to refuse the treatment. The future of such a patient remains to be seen in the
future, and the possibility of patients recovery is a matter of probability. Therefore, the
distinction is theoretically unjustifiable. Furthermore, the distinction extraneous to the
medical profession because omissions of ordinary care are as punishable as affirmative
misdeeds in a patient physician relationship. The distinction may be somehow
defensible in outside care taking professions where affirmative assistance may not be
required; however a physician's omission of readily available treatment is the textbook
definition of professional malpractice. Furthermore, the acceptance of the distinction
within the medical profession grows mistrust and suspicion between the patient and the
Conclusion 128
doctor and leads to abuse, slippery slope and vulnerability of patients. Therefore, the
distinction is practically, and normatively unjustifiable. From the point of development
and progress in medical history the distinction is methodologically degressive. There is
possibility that those patients who are suffering from deadly diseases will be killed and
the efforts needed to help such cases will not be spent. Therefore, it removes the skeptic
nature of scientific methodology which is progressive; as a result, the distinction
becomes practically unjustifiable.
Rachelss third distinction, ordinary and extraordinary medical treatment,
dissolves the distinction; the distinction is endorsed in AMAs statement and has
proponents such as Thomas Sullivan. Rachels claims that the distinction is useless and
senseless. He argues that there is no demarcation between ordinary and extraordinary
and it is sometimes permissible to omit ordinary treatments. The research shows that
the distinction as held in AMAs statement is valid and useful. The research shows that
the distinction is evolutionary and progressive. Technologically, medicine has
advanced so quickly that older understanding of the distinction seems obsolete. What
might have been considered extraordinary care a few years ago is now so commonplace
as to be called ordinary. As a matter of fact, the distinction between ordinary and
extraordinary depends on the prudence, experience, and expertise of a physician; it is
like the legal criterion of 'the reasonable man' and the criterion works in a rough and
ready way at the practical level. Therefore, it is in essence a practical matter; therefore
Rachelss claim on the issue is practically and conceptually unjustifiable. Rachelss
additional claim is that instead of debating ordinary and extraordinary medical
treatment, physicians should decide whether the life in question to be prolonged. The
Conclusion 129
claim is normatively unjustifiable because the benefit of the care to the patients health
condition is what is a real matter a doctor should be concerned about; deciding the life
and death for the patient puts the physician in an unwarranted prerogative role which is
problematic due to legal complexities, rights, duties, and autonomy. Such a judgmental
role is also prone to abuse and corruption. The doctors role is not to assess the value or
worth of the patient but that of the treatment.
As noted earlier, Rachels argues against the traditional doctrine (TDE) or
conventional doctrine on euthanasia (CDE) which is also called standard view, which
according to Rachels makes a distinction between active , killing, and passive letting
die euthanasia and prohibits active and allows passive. This view, on Rachelss
understanding, is upheld by the American Medical Association. Rachelss arguments
are aimed against AMAs position exclusively. The research shows that Rachelss
active-passive categorization of AMAs statement is a mistaken interpretation. The
statement prohibits intentional killing of terminally ill patients and allows the cessation
of extraordinary medical treatment. Rachels gives four arguments against AMAs
position and which on his formulation render the distinction between active and
passive euthanasia morally absurd. Therefore, his conclusion is that where passive
euthanasia is allowed, active euthanasia should be permitted but preferred too. The
research demonstrates the invalidity of Rachelss arguments, therefore the research
leads to invalidity of the establishment of the validity of active euthanasia on the basis
of the permissibility of so called passive euthanasia. Furthermore, the research shows
that Rachelss claim of equating active and passive euthanasia morally is theoretically
unjustifiable.
Conclusion 130
Rachelss first claim is that often active euthanasia seems more humane than
passive and therefore active euthanasia should not be only permitted but preferred too.
Rachelss reinforces his position in mercy argument. Rachelss position is based on the
suffering of terminally ill patients and that on his view such suffering can be eliminated
by active euthanasia. The research shows two main responses to Rachelss claim which
render his argument invalid.
The first response is that Rachels argues against CDE on the basis not included
in the AMAs statement. According the AMAs statement, CDE is not based on
suffering and no consideration is included on methods which produce less or more
suffering. Therefore, Rachelss argument against AMAs position is irrelevant. The
second response is made if Rachelss argument is taken against CDE on the basis of
suffering although not considered in AMAs statement. Even though, the research
forwards the reasons which render Rachelss argument unimportant, irrelevant, and
inadequate. There are two main reasons against Rachelss claim.
The first reason is that, allowing euthanasia would risk killing people who
could otherwise have had years of more life. The case from the practical point goes
against the active euthanasia, because recovery is a probability. Furthermore, the active
euthanasia in the case leads to fallacy: appeal to future. Because the defender of active
euthanasia takes the death of the patient granted. Therefore, Rachelss claim is
practically and normatively indefensible. The second reason is that modern advanced
medical technology has the most developed treatment to control the pain or suffering of
terminally ill patients. From the practical point of view suffering is irrelevant to the
Conclusion 131
issue of euthanasia due to advances in palliative care and pain medication. Therefore
active euthanasia seems undesirable. The other important notion which is connected
with suffering is the conception of the nature of suffering itself. The suffering can be
physical and it can be also mental or psychological. If suffering becomes the basis for
the permissibility of active euthanasia, then many patients who are not terminally ill
but psychologically suffering or non-terminally ill, will be subjects of euthanasia as
well. Therefore, suffering as itself is an inadequate reason for permissibility of active
euthanasia. Furthermore, suffering is actually about the attitude; it extends into
metaphysical questions about the nature of human happiness and of what constitutes a
meaningful life. On the whole, Rachless position is conceptually and practically
indefensible.
However, while it may be true any terminally ill patient might, for very good
reasons, no longer wish to prolong his or her life. These cases are cited in Rachelss
works also. However, the reason which renders such a position invalid is that the cases
are of patients who are being kept alive by extraordinary means; their death is being
prolonged due to inappropriate use of advanced medical technology. The point is that if
a person could not be cured by ordinary treatment, providing extraordinary treatment to
such a patient when death is foreseen would only create suffering. Unfortunately,
Rachels has missed this point in his works. However, Rachels argues that there are still
patients, their death is foreseen and instead of killing them they are left to die and their
dying process takes days and weeks in suffering. He therefore argues that such patients
could have been better off by active euthanasia by putting end to their suffering. The
research argues against it by two reasons. The first is that pain medication and
Conclusion 132
palliative care has made suffering irrelevant. The second reason is that those patients
who are terminally ill and their life may be miserable due to the pain which is caused by
illness, for such patients, double doctrine effect (DDE) opens the way and avoids any
need of active euthanasia. On the whole, Rachelss claim of killing a patient is
practically unjustifiable because in light of above reasons there appears no need of
killing a terminally ill patient.
Rachelss second claim is that the conventional view makes life-and-death
decisions on irrelevant grounds therefore the conventional view, CDE, is not true.
Rachels claims that those irrelevant grounds are killing and letting die; and
according to him the relevant ground should be elimination of suffering. The research
shows that the relevant grounds in CDE are the killing and termination of extraordinary
medical care. The elimination of suffering is not included; its irrelevance is shown in
the preceding arguments. Rachelss claim against CDE is theoretically unjustifiable.
Furthermore, irrelevance of killing and letting die is already shown earlier in the
criticism of the conceptual framework, and its irrelevance is further shown in the
criticism of the following claim .
Rachelss third claim is that there is no moral difference between doings and
refraining, therefore wherever refraining is allowed doing should be permitted too; in
other words, wherever passive euthanasia is allowed active should be allowed too.
Rachels attempts to demonstrate that active and passive distinction is without any
difference. The research shows that Rachelss argument is invalid due to four reasons:
(1) irrelevance to AMAs statement; (2) differences between the cases because of
Conclusion 133
intentionality, causality, and agency; (3) straw man fallacy, (4) and weak analogy.
The first reason is that the argument is irrelevant to AMAs statement which
does not make any distinction between killing and letting die, therefore Rachelss
argument against the statement is irrelevant. The second reason is that in active
euthanasia killing is intended whereas death in passive euthanasia happens naturally
without any intention. Furthermore, closely connected is the legal distinction between
ignorance of law and ignorance of fact. In legal judgments of the actions intentions are
considered; a crime committed intentionally receives greater punishment than the same
act done unintentionally. Moreover, causation and agency also makes the cases
different: in active euthanasia the cause is lethal injection and the agency is a physician,
whereas in passive euthanasia the cause and agency are the underlying disease. The
third reason is that Rachels makes very superficial and shallow claim that if a patient is
dying and could be in fact cured and doctor leaves such a patient without care and such
a patient dies and in the case killing and letting die would make no difference. This
reason is very irresponsible and subject to fallacies such as straw man fallacy, missing
the point, and equivocation; because terminating ordinary medical care when the
patient is potentially able to recover is not the subject matter of active euthanasia or
passive euthanasia. The fourth reason is that Rachelss illustration of Smith and Johns
in support of his argument commits fallacy of weak analogy, the cases are not
analogous. Because, the distinction between active and passive euthanasia lies in the
patients autonomy and ability to refuse treatment. Due the above reasons, Rachelss
claim becomes theoretically unjustifiable, because active and passive are distinctly
different.
Conclusion 134
Rachelss fourth claim is that often heard argument for the conventional view,
which states is that in passive euthanasia doctor does nothing whereas in active doctor
is the cause of death, is unsound. Because, the doctor does something, he lets the
patient die. Rachels repeats his straw man fallacy as in preceding claim; the research
shows that it is the underlying disease which causes the death, not the doctor. Therefore,
Rachelss claim becomes theoretically unjustifiable.
The research, after criticizing the conceptual framework, and Rachelss
arguments against CDE, criticizes Rachelss direct arguments for active euthanasia.
The research shows that Rachelss arguments for active euthanasia are three types: (1)
argument based on biological and biographical distinction, (2) arguments based on
CDE by dissolving the distinction between active euthanasia and passive euthanasia;
these two types can be classified as indirect arguments; and (3) direct arguments for
active euthanasia. These direct arguments are: (1) argument from mercy, (2) argument
from the best interests and golden rule, and (3) argument from autonomy. And finally,
he proposes a modest proposal on the legalization of active euthanasia. The research
shows that Rachelss argument for active euthanasia are interconnected in a way that
no argument stands on its own to support his position. His first argument from mercy
shows the problem of pure utilitarianism, to remove such a difficulty, he moves to best
interest argument, where he feels helpless and turns to the golden rule argument and the
golden rule argument ultimately depends on autonomy. Autonomy becomes
problematic and more problematic by his legislation proposal on active euthanasia.

Conclusion 135
Rachelss first argument from mercy is not different from his first argument
against CDE. Rachelss position is that it is cruel and inhumane to refuse the plea of a
terminally ill person that his or her life be ended to avoid unnecessary suffering and
pain. Allowing such a person to terminate his or her life is an act of mercy. As noted
earlier, the research demonstrates the reasons which render Rachelss argument
unimportant, irrelevant, and inadequate.
Rachelss second argument is from the best interests and golden rule. In short,
the argument holds that if active euthanasia promotes the best interest of everyone
concerned, and violates no one's rights, then it should be is morally acceptable. He
further uses Kantian categorical imperative that if we like euthanasia applied to us, we
should like it to be applied to others.
The research demonstrates three reasons which render the argument invalid.
They are: (1) the argument is based on subjective moral judgment, failing the
universalization test; (2) it may not be in my own best interests or in the best interests
of others for me to die; and (3 the argument is based on indefensible autonomy.
The research demonstrates that the best interest and golden rule arguments are
based on subjective moral judgment, therefore the arguments fail the morally
universalization test and become subject of partiality. The relevance of
universalization test is due to Rachelss acceptance of categorical imperative. In short,
if a person takes anything in his own interest, it does not guarantee that such an act
would be desirable to other people. Similarly, not everything people would wish to
have done to them is morally appropriate. Some terminally ill patients may like to be
Conclusion 136
killed, but their wishes are not enough to establish a moral rule, because they are
pointing to their own pain as a justification for carving out an exception to the general
legal and moral rule against intentionally killing the innocent. Furthermore, the
research by referring to various studies establishes the fact that even approval of some
terminally ill patients for active euthanasia is due to treatable depression; and because
of other factors the approval of such patients turn out to be a matter of completion
instead of free autonomous wish. Moreover as the research mentioned earlier the
relation of categorical imperative, Rachelss understanding of Kant turns out to be a
misinterpretation. Because, Kant argued that taking ones own life was inconsistent
with the notion of autonomy, properly understood. Autonomy, in Kants view, does not
mean the freedom to do whatever one wants, but instead depends on the knowing
subjugation of ones desires and inclinations to ones rational understanding of
universally valid moral rules. According to Kant, our rational wills are the source of
our moral duty, and it is therefore a kind of practical contradiction to suppose that the
same will can permissibly destroy itself. Given the distinctive worth of an autonomous
rational will, suicide is an attack on the very source of moral authority. Therefore, due
to these reasons, Rachelss claim of killing a terminally ill patient on the basis of the
best interest and golden rule becomes normatively and theoretically unjustifiable.
Rachelss third argument is from autonomy. Rachelss conception of
biographical life entails that a human being is autonomous; therefore, if a person
autonomously chooses to end his or her life then it is morally permissible. Rachels also
supports his position by the of analogy to the law of suicide; since it is not unlawful for
a person to commit or attempt to commit suicide, therefore such a person should be

Conclusion 137
able to seek the assistance of others in achieving this end. Importantly, the argument
from autonomy stands as the foundation of Rachelss thesis which according to him is
based on the golden rule and the best interest argument.
The research demonstrates that argument from autonomy fails to claim the
sufficient support to substantiate a pro-position for the approval of active euthanasia.
The related reasons are: (1) invalidity of civil rights claim; (2) weak analogy between
suicide and euthanasia; (3) unwarranted influence of patients autonomy on doctors
autonomy; and (4) unattainable autonomy of the terminally ill patients.
The first reason is that civil rights claim from right of property and right to
death is invalid. Because, our selves are not sufficiently distinct from our bodies to
make ownership of the body; and it does not seem to follow from having a right to life
that a person has a right to death. The second reason is that Rachelss commits fallacy
of weak analogy between suicide and euthanasia. Because, suicide is a civil liberty,
whereas euthanasia is a civil right, there exists the important distinction between them
because suicide is an autonomous and self-regarding act, and active voluntary
euthanasia requires the involvement and assistance of a second party. Furthermore, if
the argument for active voluntary euthanasia is based on dignity of human freedom and
self-determination, then it is inconsistent to ask someone else to assist. The third reason
is that by accepting patients autonomy it will have unwarranted influence on doctors
autonomy. The creation of any right to active euthanasia tends to imply a
corresponding duty on the part of someone to become actively involved in bringing
about death. Because of the adverse consequence, in the US constitutional context, the
Conclusion 138
courts have already indicated that the recognition of a constitutional right to physician
assisted suicide does not entail any duty on the part of any doctor. There is broad
agreement amongst euthanasia advocates that it would be inappropriate to impose a
duty on any person to take the life of another. Although such a duty would uphold the
autonomy of the patient who requests assistance, it is recognized that it would be an
unjustifiable interference with the autonomy of others. It is primarily to avoid the
implication of any such duty and the resulting infringement of the autonomy of other
parties that a strictly rights-based model has been widely rejected as an appropriate
basis for the legalization of active voluntary euthanasia. The fourth reason is that
autonomy of the patients is practically unattainable. Because, disease and pain
medication can cause clouding of patients mind, outside forces can influence the
patients will, furthermore the research shows that the patients who desire an early
death during a serious terminal illness are usually suffering from a treatable depressive
condition. In light of all these reasons, Rachelss claim from autonomy becomes
normatively, practically, and conceptually unjustifiable.
Rachels proposes modest proposal on the legalization of active euthanasia.
According to his proposal a physician who kills a patient would be acquitted on
proving that the patient requested so and by pleading mercy killing. Rachels claims
that under the proposal no one would be authorized to decide when a patient should be
killed. Rachels further explains that by following the proposal we would rely on the
good sense of judges and juries to separate the cases of justifiable euthanasia from the
cases of unjustifiable murder, just as we already rely on them to separate the cases of
self-defense and insanity and coercion. The research demonstrates that Rachelss
Conclusion 139
proposal on legalizing active euthanasia is problematic and after analyzing his proposal
from the legal and practical points, his proposal turns out to be impractical. The
research shows that the proposal fails to provide clear guidelines. The proposal
suggests that after mercy killing a criminal trial can acquit the physician, the
impossibility arises when the murdered person is killed and there is no one left to
follow his killing or those who follow have vested interests. The research shows that
Rachels is very naive about homicide and criminal law procedures. He suggest that
there will be no one to follow the murder case as guardians will give consent
positively, and therefore he ignores the role of the state and police . Rachels confuses
criminal trial with civil trial. The further complication arises that not many physicians
would be ready to face trials after mercy killing in absence of any guidelines and
legalized procedures. The biggest problem which the proposal fails to deal with is that
on one hand Rachels dismisses any committees which could decide the euthanasia,
whereas on the other hand he leaves the matter unto doctors that they could defend
themselves on commonsense or ignorance of fact, which gives an easy hand to a doctor
to kill people without any requirements. On the whole, Rachelss proposal is
practically unjustifiable.
On the whole, the researcher has demonstrated throughout of this study that
Rachelss conceptual framework , his arguments against CDE , his arguments for
active euthanasia, and his proposal on the legalization of active euthanasia, are
normatively, practically, theoretically, and conceptually unjustifiable.

Conclusion 140
Equally important, are the findings of this research regarding the scrutiny into
the nature of euthanasia, its definition, origin, and solution. The research agrees only
with the narrow construal definition of euthanasia: only active euthanasia. And
suggests its prohibition. To support such a position, the research develops three
propositions: (1) prolonging of death is one of the moral hazards of advanced medical
technology; (2) the cases of passive euthanasia are the cases of the natural state of
extinction; and (3) the need of active euthanasia as defended by Rachels due to some
case studies of patients is un-unjustifiable due to two reasons: (1) that the cases are
actually mishandled by the misuse of advanced medical technology and (2) if there
are terminally ill patients in anticipation of death and living in painful state such
patients could be dealt by the use of doctrine of double effect (DDE). The research
demonstrates that AMAs statement on euthanasia is valid. In addition, the patients
should not be intentionally killed and extraordinary medical treatment can be
withdrawn or withheld by the permission of the patient or due to hopeless condition of
the patient by the permission of his legal guardians. Furthermore, Rachelss
categorization of active and passive euthanasia into killing and letting die is a false
dichotomy: Rachels gives two choices; either killing or letting die, and prefers killing
to letting die. Whereas the research demonstrates that both of these choices killing and
letting die are irrelevant. The third and only choice is to stop prolongation of death by
medical technology, to allow termination of extraordinary medical care from dying
person by following legitimate procedures, and to allow use of pain medication.
Further Research and Recommendations

Conclusion 141
The researcher would like to suggest and recommend that there is need of
further research in the field of palliative care to make it more efficient and comforting.
The further research is also needed in the area of denaturalized advanced medical
services and facilities; these services and facilities are in need of ethical evaluation
which can help in setting the proper procedures for their use. Moreover, dehumanizing
nature of advanced medical technology deserves a multidisciplinary scrutiny. There is
also an urgent need of research in the field of cross-cultural family values. The
researcher believes that there are many family values which could be learnt from the
Eastern cultures in looking after the elderly and terminally ill family members.
References
Primary Sources:
Rachels, J. (1977). Medical ethics and the rule against killing. In S. Stuart, & H.
T. Engelhardt, Jr. (Eds.), Philosophical medical ethics (pp. 63-69).
Dordrecht: Reidel.
________. (1979a). Euthanasia, killing, and letting die. In J. Ladd (Ed.), Ethical
issues relating to life and death (pp. 146-163). Oxford: Oxford University
Press.
________. (1979b). Killing and starving to death. Philosophy, 54, 159-171.
________. (1980). Euthanasia. In R. Tom (Ed.), Matters of life and death (pp.
28-66). New York: Random House.
________. (1981a). More impertinent distinctions. Biomedical Ethics, 355-359.
________. (1981b). Reasoning about killing and letting die. The Southern Journal
of Philosophy, 19, 465-473.
________. (1983). Barney Clark's key. [Electronic version]. The Hastings Center
Report, 13 (2), 17-19.
________. (1984). Euthanasia and the physician's professional commitments. The
Southern Journal of Philosophy, 22, 281-285.

References 142
________. (1986a). The permissibility of ending life. Transactions of the
American Society for Artificial Internal Organs, 32, 674-676.
________. (1986b). The end of life: Euthanasia and morality. Oxford: Oxford
University Press.
________. (1993). Killing, letting die, and the value of life. Bioethica: Revista
Interdisciplinaire, 2, 271-283.
________. (1994a). Active and passive euthanasia. In A. Norcross, & B.
Steinbock (Eds.), Killing and letting die (2nd ed., pp.112 -120). New
York, USA: Fordham University Press. (Original work published 1975)
________. (1994b). More impertinent distinctions and a defense of active
euthanasia. In A. Norcross, & B. Steinbock (Eds.), Killing and letting die
(2nd ed., pp.139 -155). New York, USA: Fordham University Press.
(Original work published 1981)
________. (2001). Killing and letting die. In Encyclopedia of ethics (Vol. 2,
pp. 947-50). New York: Routledge.
________. (2002). The value of human life. Philosophical Inquiry, 24, 3-16.
________. (2003). Euthanasia: A Rebuttal of Sullivan. Retrieved January 25, 2006
from http://www.rrcc- online.com/~harolda/onethic/ethics/module3/
rachels2.htm
References 143
Secondary Sources:
Aristotle. (1999). Nicomachean ethics (T. Irwin, Trans.). Indianapolis: Hackett
Publishing.
_______. (2000). Politics . Benjamin Jowett, Trans.). Retrieved January 24,
2006 from http://classics.mit.edu/Aristotle/politics.html
Alvarez, A. (1971). The savage god: A study of suicide . New York: Random
House.
Adams, R., et al. (1992). Physician assisted suicide and the right to die with
assistance. Harvard Law Review 105:2021-2040. Retrieved March 24,
2007 from http://www.jstor.org/pss/1341556
Admiraal, P. (1989). Justifiable active euthanasia in the Netherlands. In R. M.
Baird, & S. E. Rosenbaum (Eds.), Euthanasia: The moral issues (pp.125
129). Buffalo, New York: Prometheus Books. (Original work published
Winter 1988-89)
Aquinas , St. T. (1947). Summa theologica. (Benziger Bros. ed.). Retrieved
March 20, 2007, from http://www.assumption.edu/users/gcolvert/
summa/index.html
References 144
American Medical Association, Council on Ethical and Judicial Affairs. (1992).
Deecisions near the end of life. 267 JAMA 9999, 2230-31, 2233. Retrieved
March 20, 2006, from http://jama.ama-assn.org/cgi/content/citation
/267/16/2229
Berkich , D. ( 24 March 2003 ). Rachels Arguments Against CDE. Retrieved
January 25, 2006 from http://falcon.tamucc.edu/~philosophy/courses/03-
spring/berkich/bioethics/notes/rachels_arguments_against_cde.html
Bryant, C. D. (2003). Handbook of death & dying. Michigan: University of
Michigan.
Baird, R. M. & Stuart E. Rosenbaum (ed). (1989). Euthanasia: The moral issues
Buffalo, NY: Prometheus.
British Medical Association. (2007). Withholding and withdrawing life-
prolonging medical treatment: Guidance for decision making . (3rd ed.)
Blackwell Publishing . (Original work published 1999)
Cohen-Almagor, R. (2000). Language and reality at the end of life. Journal of
Law, Medicine & Ethics, 28 (3), 267-78.
Callahan, D. (1989). Can we return death to disease? [Electronic version].
Hastings Cent Rep 1989; 19:4-6. The Hastings Center Report, 19, 52-55.
_________. (1992). When self-determination runs amok. [Electronic version].
The Hastings Center Report, 22, (2), 52-55.

References 145
Crigger , B.J. (1990). The court & Nancy Cruzan. The Hastings Center Report,
20 ( 1).
Compassion in Dying v. State of Washington Ch. No. 94-35534 (9th Cir. March
6 1996). Retrieved January 24, 2006 from http://caselaw.lp.findlaw.com/
scripts/getcase.pl?court=9th&navby=case&no=9435534&exact=1
Coleman, G. D. (1989). Assisted suicide an ethical perspective. In R. M. Baird, &
S. E. Rosenbaum (Eds.), Euthanasia: The moral issues (pp.125 129).
Buffalo, New York: Prometheus Books. (Original work published 1987)
Charlesworth , M. J. (1989). Life, death, genes, and ethics: Biotechnology and
bioethics. Crows Nest, N.S.W: ABC Enterprises for the Australian
Broadcasting.
Carr, W. H. A. (1995). A right to die . [Electronic version]. The Saturday
Evening Post, 267, 50-1.
Chobli, M. (2004 ). Suicide . Retrieved January 25, 2006 from
http://plato.stanford.edu/ entries/suicide/
Dinello, D. (1994). On killing and letting die. In A. Norcross, & B. Steinbock
(Eds.), Killing and letting die (2nd ed., pp. 192197). New York, USA:
Fordham University Press. (Original work published 1971)
Donnelly, J. (1998). Suicide: right or wrong? New York: Prometheus Books.

References 146
Descartes, R. (1984). Meditations on first philosophy. In J. Cottingham; R.
Stoothoff; & D. Murdoch ( trans.) The philosophical writings of
Descartes .New York: Press Syndicate of the University of Cambridge.
___________(1931). The philosophical works of Descartes . Haldane and G.
Ross (trans.). Cambridge.
Emanuel , E. J. (2000). Assisted suicide largely shunned. The Christian Century;
117, 34.
Euthanasia. (2008). In Merriam-Webster Online Dictionary.
Retrieved March 3, 2008, from http://www.merriam-
webster.com/dictionary/ euthanasia
Edelstein, J. (1943). The Hippocratic oath: Text, translation, and interpretation.
Baltimore: Johns Hopkins University Press.
Ferngren, G.B. (1989). The ethics of suicide in the renaissance and reformation.
In B. Brody (ed.), Suicide and euthanasia: Historical and contemporary
themes. Dordrecht: Kluwer.
Fenigsen, R. (1989). A case against Dutch euthanasia. The Hastings Center
Report; 19. Issue: 1. [Electronic Version]
Fletcher, G. P. (1994). Prolonging life: Some legal considerations. In A. Norcross,
& B. Steinbock (Eds.), Killing and letting die (2nd ed., pp. 88 -103). New
References 147
Fletcher, J. (1972). Indicators of humanhood: A tentative profile. Hastings Center
Report , 2 (5) , 1-4 . http://www.jstor.org/pss/3561570
________. (1989). Sanctity of life versus quality of life. In R. M. Baird, & S. E.
Rosenbaum (Eds.), Euthanasia: The moral issues (pp.85 97). Buffalo,
New York: Prometheus Books. (Original work published 1987)
Fried , C. (1976). Right and wrong--preliminary considerations. The Journal of
Legal Studies, 5 ( 2), 165-200.
Foot, P. (1994a). The problem of abortion and the doctrine of the double effect. In
A. Norcross, & B. Steinbock (Eds.), Killing and letting die (2nd ed.,
pp.266 -280). New York, USA: Fordham University Press. (Original
work published 1967)
______. (1994b). Killing and letting die. In A. Norcross, & B. Steinbock (Eds.),
Killing and letting die (2nd ed., pp.280 -290). New York, USA: Fordham
University Press. (Original work published 1984)
Finnis , J. (1990). Allocating risks and suffering: Some hidden traps. Cleveland.
ST. L. REV. 193, 202.

References 148
Gifford, E. (1993). Artres moriendi: Active euthanasia and the art of dying. UCLA
Law Review, 40, 1545-1583.
Gay-Williams, J. (1989). The wrongfulness of euthanasia. In R. M. Baird, & S.
E. Rosenbaum (Eds.), Euthanasia: The moral issues (pp.97 103).
Gaylin, W., Kass, L.R. , Pellegrino, E.D., & Siegler, M. (1989). Doctors must
not kill. In R. M. Baird, & S. E. Rosenbaum (Eds.), Euthanasia: The
moral issues (pp.25 29). Buffalo, New York: Prometheus Books.
Gula, R. M. (1999a). Dying well: a challenge to Christian compassion. The
Christian Century; 116, 14, 501-5.
Gorsuch, N. M. (2000). The Right to Assisted Suicide and Euthanasia.Harvard
Journal of Law & Public Policy; 23. (3).
_______ (1999b). A different death: Euthanasia and the Christian tradition, by
Edward J. Larson; Darrel W. Amundsen. Reviewed in: The Christian
Century, 116 (14 ), p. 501-5.
Harris, J. (1994). The survival lottery. In A. Norcross, & B. Steinbock (Eds.),
Killing and letting die (2nd ed., pp.257 -266). New York, USA: Fordham
References 149
University Press. (Original work published 1975)
Hohfeld W; Cook, W.W. (Ed). (1919). Fundamental legal conceptions. New
Haven, CT: Yale University Press.
Hippocrates . (2005). The oath and law of Hippocrates. The Harvard Classics,
190914. Retrieved July 3, 2007, from
http://www.bartleby.com/38/1/1.html
Hendin , H. (1997). The death debate. The Wilson Quarterly, 21.
Hendin, H., Foley, K., White, M. (1998a). Physician-assisted suicide: Reflections
on Oregon's first case. Issues in Law & Medicine, 14 (3), 243-70.
___________________________. (1998b). Oregon Death with Dignity Act.
Issues in Law & Medicine, 14 (3), 243-70. Retrieved March 3, 2008 ,
from http://www.ohd.hr.state.or.us/cdpe/chs/pas/pas.htm
Hume, D. (2004). Essays on suicide and the immortality of the soul. Kessinger
Publishing.
Hardon, J. A., S.J. (2004). Moral theology. Retrieved March 5, 2007 , from
http://www.therealpresence.org/archives/Moral_Theology/
Moral_Theology_004.htm
Irving, D. N. (1993). Scientific and philosophical expertise: An evaluation of the
arguments on "personhood". Linacre Quarterly, 60:1:18-46. Retrieved
March 2, 2006, from http://www.consciencelaws.org/Examining-
Conscience-Background/GenScience/BackGenScience06.html#01
References 150
Jacox, A., Carr, D. B., Payne, R. (1994). New clinical-practice guidelines for the
management of pain in patients with cancer. The New England Journal of
Medicine , 330 (9), 651-655.
Jonathan, B. (1994a). Whatever the consequences. In A. Norcross, & B.
Steinbock (Eds.), Killing and letting die (2nd ed., pp.167 -192). New
_________. (1994b). Negation and abstention: Two theories of allowing. In A.
Norcross, & B. Steinbock (Eds.), Killing and letting die (2nd ed., pp. 230
257). New York, USA: Fordham University Press.
Kuhse, H. & Singer, P. (1985). Should the baby live. New York: Oxford
University Press.
Kearl , M. C. (1989) Endings: A sociology of death and dying. Oxford University
Press .
Kuhse H. (1994). Euthanasia. In P. Singer (ed.), A companion to ethics . Oxford:
Blackwell.
Kant,I. ( 1785). Fundamental principles of the metaphysic of morals. (Thomas
Kingsmill Abbott, trans.). Retrieved July 2, 2006,

References 151
From http://www.grtbooks.com/
exitfram.asp?idx=3&yr=1785&aa=KA&at=FU&ref=kant&URL=http://w
ww.constitution.org/kant/metamora.htm
Koop, C. E. (1989a). The right to die: The moral dilemmas. In R. M. Baird, & S.
E. Rosenbaum (Eds.), Euthanasia: The moral issues (pp. 69 -85).
_________. (1989b). The case of Karen Quinlan. In R. M. Baird, & S. E.
Rosenbaum (Eds.), Euthanasia: The moral issues (pp. 35 -45). Buffalo,
New York: Prometheus Books. (Original work published 1976)
Kaufman, S. R. (2005). And a time to die: How American hospitals shape the end
of life. Chicago: University of Chicago Press.
Kaveny , M. C. (1997). Assisted suicide, euthanasia and the law. Theological
studies, 58, (1).
Lichtenberg, J. (1994). The moral equivalence of action and omission. In A.
Norcross, & B. Steinbock (Eds.), Killing and letting die (2nd ed., pp. 210-
230). New York, USA: Fordham University Press. (Original work
published 1982)
Larue, G. A. (1989). The case for active voluntary euthanasia. In R. M. Baird,
& S. E. Rosenbaum (Eds.), Euthanasia: The moral issues (pp. 159 -163).
References 152
Buffalo, New York: Prometheus Books. (Original work published Winter
1988-89)
Locke, J. (1894). An essay concerning human understanding. London: George
Routledge and Sons.
_______. (2001). The second treaties of government. In P. Hayden (Ed.), The
philosophy of human rights, St. Paul, MN: Paragon House.
Linacre Centre Working Party. (1982). Euthanasia and clinical practice: trends,
principles and alternatives. The Linacre Centre for Healthcare Ethics.
London. Retrieved August 27, 2007,fromhttp://www.linacre.org/lords.html
McMahan, J. (1994). Killing, letting die, and withdrawing aid. In A. Norcross, &
B. Steinbock (Eds.), Killing and letting die (2nd ed., pp.383 -421). New
Murphy, J. G. (1994). Is Killing the Innocent Absolutely Immoral? In A. Norcross,
& B. Steinbock (Eds.), Killing and letting die (2nd ed., pp.197 -210). New
McHugh, P. R . (1999) On death and dying [Review of the article Dying made
easy ] Commentary, 107 (5).
Mitchell , J.A. & Rae, S.B. ( 1996). The moral status of fetuses and embryos. In B.
Stetson (Ed.), The silent subject: reflections on the unborn in American
culture (pp. 19-33). Westport, CT : Praeger .
McIntyre, A. (2004). Doctrine of double effect. Retrieved January 25, 2006 from
http://plato.stanford.edu/entries/double-effect/
References 153
Moreland, J. P. (1990). The life and death debate: Moral issues of our time.
Westport, CT: Praeger.
Manetta, A. A., and Wells, J. G. (2001). Ethical issues in the social worker's
role in physician-assisted suicide. Health and social work, 26 (3).
More, T. (1999). Utopia (David Wootton, Trans.). Indianapolis: Hackett
Publishing.
Mair, A.W. (2007). Suicide: Greek and Roman. (J. Hastings ed.,) Encyclopedia of
religion and ethics (V.12, pp. 26-30). Varda Books.
Norcross, A. & Steinbock , B . (Eds.). (1994). Killing and Letting Die. New York:
Fordham University Press.
Omar, M. (1993). Death in America. Critical Care Clinics, 9(3), G132G, 613.
Otlowski, M. (1997). Voluntary euthanasia and the common law. Oxford:
Clarendon Press.
Official Website of James Rachels. (n.d.). Biography. Retrieved February 20,
2006, from http://www.jamesrachels.org/JboBio.htm
Plato. (1980). The laws of Plato (T. L. Pangle, Trans.). New York: Basic Books.
____. (1991). The republic of Plato (A. Bloom, Trans.). New York: Basic Books.
Paris, J. J. (1997). Autonomy and physician-assisted suicide. America, 176.
11-14 .
References 154
President's Commission for the Study of Ethical Problems in Medicine and
Biomedical and Behavioural Research. .( 1983). Deciding to forego life-
sustaining treatment. A report on the ethical, medical and legal issues in
treatment decisions. Retrieved January 19, 2007, from
http://www.lib.mcg.edu/edu/drdilemma/consult/presdent.htm
Quinn, W. S. (1994). Actions, intentions, and consequences: The doctrine of
doing and allowing. In A. Norcross, & B. Steinbock (Eds.), Killing and
letting die (2nd ed., 355 -383). New York, USA: Fordham University
Press. (Original work published 1989)
Richard, F. (1989). A case against Dutch euthanasia. [Electronic version]. The
Hastings Center Report, 19, (1), 22-30.
Steinbock, B. (1994). The intentional termination of life. In A. Norcross, & B.
Steinbock (Eds.), Killing and letting die (2nd ed., pp.120 -131). New York,
USA: Fordham University Press. (Original work published 1979)
Sullivan, T. D. (1994a). Active and passive euthanasia: An impertinent distinction?
In A. Norcross, & B. Steinbock (Eds.), Killing and letting die (2nd ed.,
pp.131 -139). New York, USA: Fordham University Press. (Original work
published 1977)
___________. (1994b). Coming to terms: A response to Rachels. In A. Norcross,

References 155
& B. Steinbock (Eds.), Killing and letting die (2nd ed., pp.155 -167). New
York, USA: Fordham University Press.
Shewmon, D. A. (1989). Active voluntary euthanasia a needless Pandora's box. In
R. M. Baird, & S. E. Rosenbaum (Eds.), Euthanasia: The moral issues (pp.
129 -141). Buffalo, New York: Prometheus Books. (Original work
published 1987)
Schiavo Case. (2007). In The Columbia encyclopedia (6th ed.). New York:
Columbia University Press.
Solomon, W. D. (n.d.). Double effect. In The encyclopedia of ethics. . Retrieved
January 27, 2006 from http://www.saintmarys.edu/
~incandel/doubleeffect.html
Stetson , B. (Ed.). (1996). The silent subject: Reflections on the unborn in
American culture. Westport, CT: : Praeger.
Seneca. (1998). On the proper time to slip the cable. In J. Donnelly (Ed.),
Suicide: Right or wrong? . (pp. 35-39). New York, USA: Prometheus
Books. . (Original work published 1917)
Tooley, M. (1994). An irrelevant consideration: Killing versus letting die. In A.
Norcross, & B. Steinbock (Eds.), Killing and letting die (2nd ed., pp.103 -
112). New York, USA: Fordham University Press.

References 156
The New York State Task Force on Life and the Law. (1994). When Death is
Sought Assisted Suicide and Euthanasia in the Medical Contex . Retrieved
February 20, 2006, from
http://www.health.state.ny.us/nysdoh/consumer/patient/chap5.htm
Trammell, R. (1994). Saving life and taking life. In A. Norcross, & B. Steinbock
(Eds.), Killing and letting die (2nd ed., pp.290 -298). New York, USA:
Fordham University Press. (Original work published 1975)
The World Medical Association. (2005). Resolution on euthanasia. Retrieved
February 20, 2007, from www.wma.net/e/policy/e13b.htm
Trowell, H. C. (1973). The unfinished debate on euthanasia. London: S.C.M.
Press.
The Robert Powell Center for Medical Ethics. (n.d.). Retrieved February 20, 2006,
from http://www.nrlc.org/euthanasia/index.html#DEFINITIONS
Vaux, K. L. (1989). Debbie's dying mercy killing and the good death. In R. M.
Baird, & S. E. Rosenbaum (Eds.), Euthanasia: The moral issues (pp. 29
35). Buffalo, New York: Prometheus Books. (Original work published
1988)
Veatch , R. (1989). Death, dying, and the biological revolution: Our last quest for
responsibility. New Haven: Yale University Press.

References 157
Wicker, C. (1989). Sentenced to life In R. M. Baird, & S. E. Rosenbaum (Eds.),
Euthanasia: The moral issues (pp. 15 23). Buffalo, New York:
Prometheus Books. (Original work published April 23, 1989)
Warren, M. A. (1996). On the moral and legal status of abortion. In T.A. Mappes
& D. DeGrazia (Eds.) Biomedical ethics, 4th ed. (pp. 434-440). New
York: McGraw-Hill. Retrieved January 25, 2006 from
http://instruct.westvalley.edu/lafave/warren_article.html
Wanzer, H., Federman, DD., Adelstein, SJ. , Cassel, CK., Cassem, EH., Cranford,
RE., et al. (1990). The physician's responsibility toward hopelessly ill
patients: A second look. In J. J. Walter, & T. A, Shannon (Eds.) Quality
of life: The new medical dilemma, (pp. 282-292). Paulist Press .
Young, R. (2007). Voluntary euthanasia. Stanford Encyclopedia of Philosophy.
Retrieved February 20, 2006, from
http://plato.stanford.edu/entries/euthanasia-voluntary/

James Rachels's Defense of Active Euthanasia: A Critical & Normative Study

Caricato da

Informazioni sul documento

Titolo originale

Copyright

Formati disponibili

Condividi questo documento

Condividi o incorpora il documento

Opzioni di condivisione

Hai trovato utile questo documento?

Questo contenuto è inappropriato?

Copyright:

Formati disponibili

James Rachels's Defense of Active Euthanasia: A Critical & Normative Study

Caricato da

Copyright:

Formati disponibili

James Rachelss Defense of Active Euthanasia:

A Critical & Normative Study

Mr. Mohammad Manzoor Malik

A THESIS SUBMITTED IN PARTIAL FULFILLMENT OF THE

Graduate School of Philosophy and Religion

deserves a critical and normative analysis because of its dehumanizing consequences.

The researcher demonstrates that Rachelss position is conceptually, theoretically,

Firstly, the researcher criticizes Rachelss conceptual framework which

euthanasia because of their conceptual, theoretical, and practical inadequacies.

extraordinary medical treatment is not valid.

Secondly, the researcher argues against Rachelss arguments against CDE.

argument from autonomy fails to claim the sufficient support to substantiate a

patients autonomy, and (4) unattainable autonomy of the patients. Furthermore,

research demonstrates that Rachelss proposal on legalizing active euthanasia is

problematic and impractical.

Finally, the researcher shows that Rachelss categorization of active and

of death by advanced medical technology and permitting termination of extraordinary

medical care from dying person by following legitimate procedures.

Chapter One: Introduction 1

1.1. Background, Significance, & Scope of the Study 1

1.2. Thesis Statement 19

1.4. Limitation and Methodology of the Research 19

Chapter Two: Exposition of Rachelss Thought on Euthanasia 21

2.2. Rachelss Euthanasian Conceptual Framework 23

2.2.1. Biological Life and Biographical Life 23

2.2.2. Killing and Letting Die 24

2.2.3. Ordinary and Extraordinary Means of Treatment 27

2.3. Rachelss Arguments against Traditional Doctrine

2.3.1. Often Active Euthanasia Seems More Humane Than Passive 32

2.3.2. The Conventional View Makes Life-And-Death Decisions

2.3.3. There is no Moral Difference between Doing and Refraining 34

2.3.4. Arguments in Favor of the Conventional View do not Work 35

2.4. Rachelss Arguments for Active Euthanasia 36

2.4.1. The Argument from Mercy 37

2.4.2. The Best Interests and Golden Rule Argument 37

2.4.3. The Argument from Autonomy 40

2.5. Proposal for Legalization of Active Euthanasia 42

Chapter Three: Critique of Rachelss Thought on Euthanasia 45

3.2. Criticism of Rachelss Conceptual Framework 46

3.2.1. Criticism of Biological and Biographical Life 46

3.2.2. Criticism of Killing and Letting Die 53

3.2.2.1. Killing and Letting Die: An Irrelevant Distinction 54

3.2.3. Criticism of Ordinary and Extraordinary Means of Treatment 61

3.3. Criticism of Rachelss Arguments against Traditional

Doctrine on Euthanasia (TDE) 66

3.3.1. Criticism of that often Active Euthanasia Seems More

Humane than Passive 67

3.3.2. Criticism of the Conventional View Makes Life-And-Death

Decisions on Irrelevant Grounds 75

3.3.3. Criticism of that there is no Moral Difference between

Doings and Refraining 77

3.3.4. Criticism of that the Arguments in Favor of the Conventional

View do not Work 86

3.4. Criticism of Rachelss Arguments for Active Euthanasia 88

3.4.1. Criticism of the Argument from Mercy 90

3.4.2. Criticism of the Best Interests and Golden Rule Argument 90

3.4.3. Criticism of Rachelss Argument from Autonomy 96

3.4.3.1. Self-determination and Euthanasia 97

3.4.3.2. Analogy of Euthanasia with Suicide 100

3.4.3.3. Right, Liberty and Euthanasia 101

3.4.3.4. Autonomy of Patients 103

3.5. Criticism of Rachelss Proposal of Legalizing Active Euthanasia 105

3.6. Modern Advanced Medical Technology and Euthanasia 107